198603535-10-17-2023-28-AS-TVAO-CXNUAV-20231117142520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:34:12 PM

Substantiated

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
10/11/2023 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231011091749

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: 124	DATE:	10/17/2023
		UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	William Woods		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident is being illegally evicted.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/17/23 regarding the above allegation. LPA Ramirez was met by Assistant Administrator William Woods 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 – R4 ), copies of Resident #1 (R1): Face Sheet, proof of service dated 09/19/23, signed Admission Agreement, signed Facility House Rules, 30-Day to Terminate dated 09/19/23, and physical plant tour.

See 809-C for continuation.

Substantiated

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)

Page: 1 of 5

Control Number 28-AS-20231011091749

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following. Regarding Allegation: Resident is being illegally evicted.- It is alleged R1 is being illegally evicted. On 9/19/23, LPA Ramirez received notification of R1’s 30-Day to Terminate. The eviction alleged R1 failed to comply with the general policies of the community, R1’s conduct poses a danger to themselves or others at the community, R1 was disruptive and created unsafe conditions, and R1 engaged in conduct that violated federal, State or local laws, or ordinances. Facility staff could not provide LPA Ramirez with a police report or arrest report from local law enforcement that indicates R1 violated federal, State, local laws or ordinances. LPA Ramirez could not locate any Special Incident Report (SIRs) indicating R1 was found with illegal drugs in their persons or in their accommodation. On 09/22/23, LPA Ramirez reviewed R1 30-Day to Terminate and contacted Administrator Mnoyan. LPA Ramiez advised Administrator Mnoyan against eviction for R1 based on lack of criminal evidence of R1 allegedly selling illegal drugs in the facility. Administrator Mnoyan advised LPA Ramirez that local law enforcement refused to search R1’s room and advised the facility to seek a warrant so that local law enforcement may search R1’s room. Interviews with staff revealed R1 has never been found with illegal drugs in R1’s possession or found in R1’s room. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Exit interview conducted. One (1) deficiency is being cited. A copy of this report, 809-D, and appeals rights was provided.

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)

Page: 2 of 5

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
10/11/2023 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231011091749

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: 124	DATE:	10/17/2023
		UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	William Woods		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident is being harassed by staff.
Facility has bed bugs and insects.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/17/23 regarding the above allegations. LPA Ramirez was met by Assistant Administrator William Woods 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 – R4 ), copies of Resident #1 (R1): Face Sheet, proof of service dated 09/19/23, signed Admission Agreement, signed Facility House Rules, 30-Day to Terminate dated 09/19/23, and physical plant tour.

See 809-C for continuation

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)

Page: 3 of 5

Control Number 28-AS-20231011091749

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Resident is being harassed by staff- It is alleged R1 is being harassed by staff. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. LPA Ramirez viewed signs posted in facility main reminding all residents, staff and visitors of Residents’ Rights and how to report any types of abuse or harassment. LPA Ramirez toured R1’s room and did not observe any hazards. LPA Ramirez toured facility grounds and observed several staff providing care and supervision. LPA Ramirez did not observe any staff harassing residents during visit. 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 has bed bugs and insects- It is alleged the facility has bed bugs and insects in R1’s room. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents deny this allegation. LPA Ramirez toured rooms: 120, 123, 132, 145,153 and 159. LPA Ramirez inspected mattresses, linens and carpets in each room. LPA Ramirez did not observe bed bugs or insects in any of the rooms. LPA Ramirez did not locate any medical records treatment for R1 receiving treatment for bed bug bites. LPA Ramiez did not locate any work orders to treat any resident rooms for bed bugs. 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.

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)

Page: 4 of 5

Control Number 28-AS-20231011091749

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 10/25/2023 Section Cited CCR 87224(d)	1 2 3 4 5 6 7	(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee will rescind eviction.
	8 9 10 11 12 13 14	Licensee did not provide R1 in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.	8 9 10 11 12 13 14	Licensee could not provide factual evidence that resident failed to comply with state or local law and received written notice of the alleged violation.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5