198603535-10-17-2023-28-AS-RORN-CWWLFK-20231024084312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:16:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2023 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230823112141

FACILITY NAME:	SANTA ANITA ASSISTED LIVING		FACILITY NUMBER:	198603535
ADMINISTRATOR:	MAYA S MNOYAN		FACILITY TYPE:	740
ADDRESS:	5600 GRACEWOOD AVENUE		TELEPHONE:	(626) 442-8410
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	150	CENSUS: 126	DATE:	10/17/2023
		UNANNOUNCED	TIME BEGAN:	03:10 PM
MET WITH:	William Woods		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff hit resident in care.
Facility staff did not safeguard resident's personal belongings.
Facility staff did not ensure resident's record was completed accurately.

INVESTIGATION FINDINGS:

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**This is a corrected version of previous report dated 8/25/23. No changes in findings. Verbiage on 9099 was corrected to reflect correct staff identifier (S1). **
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/25/23 regarding the above allegations. LPA Ramirez was met by Staff #1(S1) and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews (S1 – S4), Resident #1-4 interviews (R1 – R3, R5),attempted interview of Resident#4 (R4), copies of Resident #4 (R4): Admission agreement, Emergency and identification, Preplacement Appraisal Information dated 1/19/23, Physician’s Report 1/24/23, other pertinent documents and physical plant tour.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230823112141

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA ANITA ASSISTED LIVING	FACILITY NUMBER: 198603535
	VISIT DATE: 10/17/2023

NARRATIVE

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Regarding allegation(s): Facility staff hit resident in care. It is alleged an unknown staff member hit Resident #4 (R4). Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. LPA Ramirez attempted to interview R4 in R4’s accommodation. R4 denied entry to LPA Ramirez and refused to be interviewed. LPA Ramirez reviewed R4’s medical file and did not observe and Special Incident Reports (SIR) indicating R4 sustained any injures within the last 2 weeks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility staff did not safeguard resident's personal belongings. It is alleged facility staff stole R4’s wallet and jewelry. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. During the interview of R5, it was revealed that R5 found R4’s wallet in the dining room couch on 8/24/23. According to Administrator Mnoyan, R5 stated they found the wallet and the facility returned it back to R4. R4 refused to be interviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility staff did not ensure resident's record was completed accurately. It is alleged that facility staff are not ensuring R4’s medical records are current. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. R4 was admitted into the facility on 1/19/23. Physician’s Report dated 1/24/23 and Preplacement Appraisal Information dated 1/19/23 both indicate R4 is ambulatory and does not require assisted devices to get around the facility. Four (4) out of the four (4) staff interviewed confirm R4 is ambulatory without assisted devices. R5 revealed that R4” accidentally left their wallet on dinning room couch and walked away.” LPA Ramirez could not find any discrepancies while reviewing R4’s file. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided to Administrator Mnoyan.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC9099 (FAS) - (06/04)

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