198603535-6-14-2024-28-AS-LHIS-D7MNCC-20240729102031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 06/14/2024
Date Signed: 06/14/2024 01:30:46 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
06/11/2024 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240611084216

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: 145	DATE:	06/14/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maya Mnoyan		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to resident resulting in fall.
Staff physically abused resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint investigation regarding the above allegations. LPA met with Administrator, Maya Mnyoyan who assisted with the visit.

Regarding the allegation that : Staff did not provide adequate supervision to resident #1 resulting in fall. The investigation consisted of interviews with Administrator, staff #1 - staff #3, and resident #2 - resident #11. LPA also reviewed resident #1's file, and obtained copies of specific documents, including incident report dated 6/9/24.

The investigation revealed the following : Administrator and staff interviewed stated that on 6/9/24, resident #1 experienced a fall at 10:42am while a caregiver was assisting resident #1 from a chair to her bed. Resident #1 was assessed and not found to have any injuries. Resident #1 experienced a second fall at 1:40pm, which was unwitnessed. Staff #2 assessed resident #1 and observed that resident #1 stated they were not in pain, and there were no visible injuries. Administrator stated that the doctor advised the facility to send resident #1 to the hospital for a more thorough assessment. Resident #1 is currently hospitalized.

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240611084216

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: 06/14/2024

NARRATIVE

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Administrator and staff interviewed denied the allegation. Four out of four staff interviewed stated that staff do provide adequate supervision to residents in care. Staff interviewed stated that if a resident experiences a fall, they are immediately assessed for injuries. Residents interviewed were unable to corroborate the allegation. Nine out of ten residents interviewed stated that staff provide adequate supervision to residents in care. Resident #1 is currently hospitalized and was unable to be interviewed. Although resident #1 did sustain a fall, the preponderance of evidence does not show that any Title 22 regulations were violated.

Regarding the allegation that : Staff physically abused resident #1 in care. The investigation consisted of interviews with Administrator, staff #1 - staff #3, and resident #2 - resident #11. Administrator and staff interviewed denied the allegation. Four out of four staff interviewed stated that they have not observed any staff physically abuse any of the residents in care. Staff interviewed stated that they have not had any resident(s) report any physical abuse. Resident(s) interviewed were unable to corroborate the allegation. Ten out of ten residents interviewed stated that they have not observed any staff physically abuse any resident(s) in care. Resident #1 is currently hospitalized and was unable to be interviewed.

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 to Administrator.

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

LIC9099 (FAS) - (06/04)

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