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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 05/25/2022
Date Signed: 05/25/2022 10:33:08 AM


Document Has Been Signed on 05/25/2022 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:DEOSO, GEMMAFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 56DATE:
05/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Sabina Nayberg, Administrator TIME COMPLETED:
10:45 AM
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A pre licensing visit was conducted on 4/21/22 by Licensing Program Analyst (LPA) Jewel Baptiste. The following deficiencies was observed during the visit:
  1. Broken Faucet in room #143
  2. Cracks in tub and grab bars in room#136
  3. ·Skids matt missing in room #104, #106, #114, #131, #136, #157
  4. Broken call light in room # 135
  5. Water temperature in room #106, #117, #118, #119, # 143, #135, #132 was not within the regulation of 105-125 degrees F.

On 5/25/22 at 9:09 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an announced pre licensed visit to clear deficiencies from visit on 4/21/2022. Upon arrival LPA met with assistant administrator William Woods and explain the reason for the visit.

Report Continued on 809c

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA ANITA ASSISTED LIVING
FACILITY NUMBER: 198603535
VISIT DATE: 05/25/2022
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The following deficiencies was cleared during the visit:

1. Broken Faucet in room #143

2. Cracks in tub and grab bars in room#136

3. Skids matt missing in room #104, #106, #114, #131, #136, #157

4. Broken call light in room # 135

5. Water temperature in the following rooms was within the regulation of 105-125 degrees F

· #106- 109.7

· #117 -107.4,

· #118- 109.6,

· #119- 105.1,

· # 143- 109.2,

· #135 -107.9,

· #132 –106.2

Component III was reviewed during the visit due to the change of administration.

All the above corrections was made and exit interview was conducted with administrator and assistant administrator and a copy of the report was issued.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC809 (FAS) - (06/04)
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