198603535-12-12-2023-28-AS-LHIS-D2TMCH-20240226082934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:54:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/30/2023 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231030142152

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:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	William Woods		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not prevent resident from attacking another resident resulting in injuries
Staff did not notify resident's authorized representative of incident
Staff did not notify residents authorized representatives of COVID outbreak

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Assistant Administrator, William Woods who assisted with today's visit.

Regarding the allegation that : Staff did not prevent resident from attacking another resident resulting in injuries. The investigation consisted of interviews with Resident #1 - Resident #12, Assistant Administrator, and staff #1 - staff #4. The investigation revealed the following : Assistant administrator stated that on 10/28/23, resident #1 and resident #13 had a disagreement, and resident #1 pushed resident #13. Assistant administrator stated that the incident happened in the lobby area of the facility, and a special incident report was submitted to Community Care Licensing. Staff interviewed stated that resident #13 was assisted and assessed for injuries. Assistant administrator and staff interviewed stated that staff do try to intervene and prevent altercations between residents from occurring. Residents interviewed were unable to corroborate the allegation. 12 out of 12 residents interviewed stated that staff do try to intervene and prevent alteracations from occurring.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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-20231030142152

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/12/2023

NARRATIVE

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Regarding the allegation that : Staff did not notify resident's authorized representative of incident. The investigation consisted of interviews with Resident #1 - Resident #12, Assistant Administrator, and staff #1 - staff #4. Assistant administrator and staff interviewed stated that the facility does notify residents' authorized representative(s) of incident(s). Staff #1 stated that he contacted the authorized representative(s) listed on resident #13's contact list, and was able to contact resident #13's son. Residents interviewed were unable to corroborate the allegation. 12 out of 12 residents stated that they were not sure if the facility contacts residents authorized representative(s) of incident(s).

Regarding the allegation that : Staff did not notify residents authorized representatives of COVID outbreak. The investigation consisted of interviews with Resident #1 - Resident #12, Assistant Administrator, and staff #1 - staff #4. Assistant administrator and staff interviewed stated that the facility did notify the resident(s) who have authorized representatives of the Covid outbreak at the facility. Residents interviewed were unable to corroborate the allegation. 12 out of 12 residents interviewed stated that they are self responsible. They stated that they don't know if the facility notified residents authorized representatives of COVID outbreak.

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 conducted, and a copy of the report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

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