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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 11/20/2023
Date Signed: 11/20/2023 02:39:00 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
11/17/2023 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231117101225
FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:MAYA S MNOYANFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 121DATE:
11/20/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Maya Mnoyan - Executive DirectorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff mismanaged residents medications.
Staff did not ensure faciltiy was free from bed bugs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced initial complaint investigation regarding the above allegations. LPA met with Maya Mnoyan - Executive Director and explained the purpose of the visit.

The investigation consisted of the following:
LPA obtained copies of Staff and Resident Roster’s, copies of Resident #1 (R1): Face Sheet, Current Physician Report, Discharge Paperwork from Hospital (of most recent visit), and Medical Documents. LPA conducted facility tour and inspected 6 client bedrooms. LPA conducted Staff #1 - 5 interviews (S1 – S5) and Resident #1-10 interviews (R1 – R10).


Continued on 809-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
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 3
Control Number 28-AS-20231117101225
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: 11/20/2023
NARRATIVE
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The investigation revealed the following:

Allegation: Staff mismanaged residents’ medications.


It is alleged that R1 was given medication that was not needed. Medication in question was a 1% topical lotion, R1 states that S2 was giving them the wrong medication as it should have been 5%. LPA reviewed discharge paperwork from R1’s file and medication that was prescribed by doctor was a 1% topical lotion, this error was not done due to staff changing a medication. R1 cancelled the medication, and a new order was given by doctor for the correct 5% topical lotion. Interviews with S1 and S2 revealed that staff are not able to make any adjustments to resident medications and all medications are prescribed by doctor and administered per doctor’s orders. Interview with S2 revealed that S2 followed up with a phone call to doctor as medication prescribed is usually used to treat scabies and as precaution wanted confirmation as isolation protocols would follow if this was the case, doctor stated that the medication is provided to help cure mild skin allergies/irritations and did not confirm nor deny this was caused by bed bugs. LPA interviewed 10 Residents and 8 out of 10 Residents denied the above allegation and state they are confident that the facility manages their medication correctly and they are administered their medication per doctor’s orders.

Allegation: Staff did not ensure facility was free from bed bugs.
It is alleged that R1 has bed bugs in their room. LPA toured facility, inspected R1’s bedroom along with 5 other resident bedrooms, Rooms inspected were #’s 126, 145, 171, 177, 178, 186. LPA inspected the mattresses linens and carpets in each room and did not observe bed bugs or insects in any of the bedrooms. LPA reviewed R1 medical records and observed that R1 was provided with medications to cure a skin disorder, R1 was provided with Bed Bug Information Sheets at discharge, however, the diagnosis of skin condition did not identify that it was due to bed bug bites. LPA reviewed R1’s medical records and there are records showing R1 has had minor cuts/abrasions and skin tear treatment since 2/29/2023. LPA interviewed 5 staff and 5 out of 5 staff stated that no other resident besides R1 has brought the concern of bed bugs to their attention. 5 out of 5 staff stated that although they have not seen the bed bugs R1 claims to have in their room, there have been precautionary measures taken to ensure resident does not have bed bugs. Mattress has been switched out on three different occasions in R1’s room, housekeeping cleans regularly using a steamer on resident rooms twice weekly and weekly laundry is done where sheets are washed and replaced. LPA interviewed 10 Residents and 9 out of 10 Residents stated that their rooms are cleaned daily, sheets are washed weekly and they have never had any issues with bed bugs in their rooms.

Continued on LIC 9099-C
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20231117101225
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: 11/20/2023
NARRATIVE
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Based on statements and interviews conducted with staff and Residents and review of Resident #1 files, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to Executive Director Maya Mnoyan.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3