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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 06/14/2024
Date Signed: 06/14/2024 06:24:04 PM


Document Has Been Signed on 06/14/2024 06:24 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 LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:MAYA S MNOYANFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 143DATE:
06/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:24 PM
MET WITH:Administrator Maya MnoyanTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 06/14/2024, stemming from initial complaint investigation conducted on 06/14/2024. LPA Ramirez was greeted by Administrator Maya Mnoyan.

Case Management-Deficiencies findings:

Resident#1 (R1) was admitted into the facility on 2/3/2023 and has an admission agreement dated 2/3/2023. LPA Ramirez discovered R1 and facility representative signed a document indicating the following “R1 has agreed to stay in this community here at Santa Anita Assisted Living under the following conditions: Stays in the building every day without leaving overnight. (Building closes at 10pm). Pay rent every single month on the 5th, starting June 5th, 2024, with no missed payment. If these conditions are not followed and being done, resident has agrees to leave facility and discharge themselves.” This document is dated 5/31/2024. Review of R1’s Physician Report (LIC 602) dated 3/4/2024, indicates R1 may leave the facility unassisted. R1 is self-responsible and is not conserved. Per Title 22, Division 6, Chapter 8- 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.


Interview with R1 revealed R1 left the facility on 6/7/24. On 6/10/24, Administartor Mnoyan phoned R1 to advise R1. they broke their agreement signed on 5/31/24 and could not return to the facility. As of 6/14/2024, R1 has not returned to the facility. LPA Ramirez and Administrator Mnoyan phoned R1 and R1 was told they may return to the facility. R1 agreed to phone the facility to get transportation arrangements. Facility staff violated R1’s personal rights by asking R1 to sign above referenced document; which violates R1's right to leave the facility freely, interfere and retaliate against R1 for exercising their rights.

One deficiency was cited during this visit. A copy of this report, 809-D and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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Document Has Been Signed on 06/14/2024 06:24 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
87468(a)(3)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all
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This requirement was not met as evidence by:
R1 was asked to sign a document violating thier right to leave the facility freely, interfere and retaliate against R1 for exercising their rights.
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of the following personal rights: (3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.
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Licensee will retrain staff on this regulation and send proof of re-training by 6/28/24. Licensee will recind this notice by 6/17/24 and send proof to LPA Ramirez via email.

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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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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