198603535-8-1-2024-28-AS-RORN-D8JNZZ-20240827105509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:32:25 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
07/25/2024 and conducted by Evaluator Sanjay Vaid

COMPLAINT CONTROL NUMBER: 28-AS-20240725105346

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: 149	DATE:	08/01/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Maya Mnoyan		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Licensee did not provide responsible party with a refund.

INVESTIGATION FINDINGS:

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***This licensing report supersedes licensing report (LIC 9099) dated 07/30/24.***

Licensing Program Analyst (LPA) Vaid conducted a follow complaint visit to the facility. Upon arriving at the facility, LPA met with Wellness Director Yumi Ludwig, Administrator Maya Mnoyan arrived shortly after to assisted with the visit. LPA discussed and explained the purpose of today’s visit, which was to reissue the findings issued on/07/30/24.

On todays, visit LPA spoke and toured the physical plant along with Maya Mnoyan and did not observe any Health and Safety concerns.

During today’s visit LPA obtained resident/ staff roster, complete admissions agreement.

CONTINUED ON 9099 A......

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

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-20240725105346

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA ANITA ASSISTED LIVING	FACILITY NUMBER: 198603535
	VISIT DATE: 08/01/2024

NARRATIVE

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***This licensing report supersedes licensing report (LIC 9099) dated 07/30/24.***

On 07/30/24 LPA Vaid conducted an initial complaint visit, during visit, LPA Vaid obtained resident/ staff roster, admissions agreement, and email correspondence showing responsible party’s email with facility officers. LPA also interviewed administrator Maya Mnoyan.

7 out 0f 7 residents could not corroborate the allegation and 5 out of 5 staff deny the allegation.
Based on interviews conducted and documents review the findings indicate the facility was notified on 04/13/24 by the responsible party that the belongings of R1 were being moved to the rehab center where R1 would be residing for the remainder of their rehabilitation after being discharged from the hospital. On 04/16/24 R1 passed away, and on 04/17/24 responsible party notified the administrator via email correspondence, to start the prorated refund. The business office notified the responsible party the refund needed to go thru the corporate office, the corporate office would close out all outstanding accounts and the refund would be sent directly to the responsible party. R1’s responsible party (RP) contacted facility staff S1 and S2 via email correspondence to inquire of the refund on 05/17/24, 06/09/24, 06/17/24, 07/14/24, and 07/23/24. R1’s RP was assured the by facility staff S1 and S2 the refund was being handled. The facility failed to refund the prorated funds to R1’s responsible party within 15 days after property was removed on 04/13/24. Notification by the responsible party on 04/17/24 of R1’s death on 04/16/24 via email correspondence, as agreed to in the admissions agreement section VIII -termination and section C-death, dated 02/03/24.

Therefore, based on LPA’s observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.

Exit interview was conducted and copy of this report and appeals rights were discussed and given to the Administrator.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240725105346

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 08/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/01/2024 Section Cited CCR 87507(5)(c)	1 2 3 4 5 6 7	Admission Agreements 87507(5) Refund conditions.(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility... the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.	1 2 3 4 5 6 7	Administrator produced the proof of refunded monies to R1's responsible party on 07/29/24. Proof of correction has been satisfied.
	8 9 10 11 12 13 14	This requirement not met as evidence by: Based on interviews and record review, licensee failed to refund monies with 15 days after R1's belonging were removed and after R1's death. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024

LIC9099 (FAS) - (06/04)

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