198603535-5-22-2024-28-AS-CDCN-D5HSTL-20240522140939

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 05/21/2024
Date Signed: 05/22/2024 02:10:00 PM

Document Has Been Signed on 05/22/2024 02:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 141	DATE:	05/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Maya Mnoyan, Administrator		TIME COMPLETED:	04:45 PM

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	Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 5/21/24. LPA arrived unannounced and met with Administrator, Maya Mnoyan. The purpose of the visit was explained. The facility is licensed for 150 non-ambulatory residents, ages 60 and over, of which (20) may be bedridden. There is a hospice waiver approved for (20) residents. LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool. The following were observed: Infection Control: The facility is continuing to follow their Infection Control Plan. Staff are using gloves to assist residents and performing adequate hand hygiene. Staff are receiving annual in-service training on Infection Control. Operational Requirements: The facility is operating within the approved fire clearance. Facility accepts and retains residents with dementia. The liability insurance is current and has the sufficient amount covering the injury of residents and guests. Physical Plant & Environment Safety: The single story facility is located in the residential area. LPA randomly selected 12 rooms to inspect as well as the common areas. The hot water temperature in the rooms was measured within the range of 105-120 degree F. The common areas are clean and furnished. Each resident room has the required furniture, closet space, and lighting. The rooms have a call cord located by the residents bed and in the bathrooms. The fireplace is not in use and adequately screened. There are no items obstructing the walkways. There is no swimming pool on the premises. The facility has smoke and carbon monoxide combo detectors that are hardwired and connected to the fire department. Food Service: Adequate food supplies of 2 day perishable and a week of nonperishable were observed. The kitchen area is clean and free of rodents and insects. Food is properly covered to avoid contamination. Planned Activities: Facility has a full-time Activity Director providing activities to residents. There are planned daily activities and are posted on the bulletin board.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/21/2024

NARRATIVE

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Staffing: Per the administrator, there is sufficient staffing on each shift. The overnight shift staff are all awake and providing supervision to residents. There is at least one staff who is CPR & First Aid certified on each shift at all times.
Personnel Records-Training: LPA reviewed 6 personnel records. The administrator's (Maya Mnoyan) certificate expires on 10/9/25. Staff are fingerprint cleared and associated to the facility. Staff have appropriate dementia care training and ongoing training.
Resident Rights/Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff.
Resident Records/Incident Reports: LPA reviewed 14 resident files. Resident files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, pre-appraisal form, and care plan.
Incidental Medical and Dental: Medications are centrally stored in the medication room. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed 14 residents' medications and did not find any discrepancies.
Disaster Preparedness: The facility has the updated LIC610E Emergency Disaster Plan posted. Annual training is provided to staff. The facility conducts monthly disaster drills for different shifts and are documented.
Residents with Special Health Needs: Residents utilizing oxygen tanks have the proper sign posted outside their doors. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence.

There are no deficiencies observed during the visit today. An exit interview was held and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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