198603535-11-14-2023-28-AS-TVAO-CXSUFD-20231121143233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 11/14/2023
Date Signed: 11/14/2023 01:39:52 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
10/11/2023 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231011133210

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:	11/14/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Maya Mnoyan		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility grounds are littered with trash and cigarette buds.
Resident was given incorrect medication by staff.
Facility emergency call button in resident room is in disrepair all.

INVESTIGATION FINDINGS:

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**This is corrected version of previous report dated 10/17/23. Verbiage on 9099-C was corrected from " Three (3) out of the four (4) staff interviewed deny this allegation" to " Three (3) out of the four (4) residents interviewed deny this allegation." No changes to findings.** 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, Physician Report Dated 08/25/21, Medication Administration Record (MAR) for the months of September and October, Physicians Orders dated May 2023, current medications as of 10/17/23, review of medical file, 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: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

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-20231011133210

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: 11/14/2023

NARRATIVE

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The investigation revealed the following. Regarding Allegation(s): Facility grounds are littered with trash and cigarette buds.- At 11:17 am, LPA Ramirez toured indoor and outdoor of the facility grounds. LPA Ramirez did observe several discarded cigarette buds in planter located on the outside main entry walkway of the facility. LPA Ramrez observed staff inspecting front grounds with a broom and scoop pan, and removing discarded cigarette buds from front grounds. LPA Ramirez did not observe trash scattered around facility grounds. 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.

Resident was given incorrect medication by staff.- It is alleged facility staff gave R1 incorrect medication. Four (4) out of four (4) staff interviewed deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. LPA Ramirez reviewed R1’s Medication Administration Record for the months of September and October. LPA Ramirez did not observe and discrepancies. LPA Ramirez reviewed R1’s medical file and could not locate any medical records indicating R1 was sent to the hospital or treated for being over medicated or under medicated. LPA Ramirez did not observe and Special Incident Reports (SIRs) for R1 indicating medication was given incorrectly or missed. 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 emergency call button in resident room is in disrepair.- It is alleged the facility emergency call button in R1’s bathroom is in disrepair. LPA Ramirez toured R1’s room (159) and tested emergency call button located in bathroom. Initially call button was not working properly however, this was due to call button not being reset. After second attempt and reset, emergency call button functioned accordingly. LPA Ramirez tested emergency call buttons in bathrooms: 120 and 132. LPA Ramirez observed these to be in working order. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. 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 was conducted. No deficiencies were cited during this visit. A copy of this report 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: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

LIC9099 (FAS) - (06/04)

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