198603535-4-17-2025-28-AS-FFIS-DG3UNP-20250425154413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 04/04/2025
Date Signed: 04/17/2025 03:11:03 PM

Unsubstantiated

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
01/31/2025 and conducted by Evaluator Sanjay Vaid

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250131145836

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:	04/04/2025
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Joel Niblett- Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff physically abused resident, resulting in resident sustaining a bruise

INVESTIGATION FINDINGS:

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*** This licensing report issued on 4/17/25 supersedes that licensing report dated 4/4/25, LPA Vaid obtained additional information, however, the investigation findings will remain the same***

Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit today regarding the listed allegation and to re-deliver complaint investigation finding. Met with Joel Niblett-Administrator and explained purpose of the visit. Requested and obtained staff and client rosters. Conducted a tour of the facility and did not observe any health and safety concerns.
On 02/03/25, Licensing Program Analyst (LPA) S Vaid conducted an initial 24-hour complaint investigation visit for the above allegation. LPA met with Ruth Villa, Wellness Director and the purpose of the visit was discussed. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff #1-#8 (S1-S8) and residents #1-#10 (R1-R10). LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, residential appraisal-individual service plan.
CONTINUED 0N 9099C...............

Unsubstantiated

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: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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-20250131145836

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: 04/04/2025

NARRATIVE

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Caregiver sign-in for month of January. Residents census and resident roster, caregiver staff roster (01/20/25-01/31/25), S4 employee file-caregiver duties and disciplines.

Regarding the allegation: Staff physically abused resident, resulting in resident sustaining a bruise. It is alleged that resident #1 (R1) was punched in the arm by a caregiver who changes residents’ diapers during NOC shift. Eight (8) out of eight (8) staff interviewed deny the allegation. All staff interviewed deny physically abusing the R1 or any residents. Nine (9) out of ten (10) residents interviewed were not able to corroborate the allegation. Residents interviewed stated; they have not encountered issues with staff during continence care. Interview with R1 revealed that R1 is does not recall how R1 sustained the bruising.
The investigation revealed that S4 recalled an incident that occurred between R1 and S4 on 01/23/25, S4 reported that S4 explained to R1 that the color of the adult brief was the correct size, however R1 did not want S4 to use that color and preferred a different color, which per S4 was the incorrect size for R1. S4 proceeded to change R1 into the correct size adult brief. Per S4, R1 became upset regarding the color of the adult brief that S4 was using to change R1, resulting in R1 hitting S4 with R1’s arms. S4 reported holding up S4’s arms and hands in a cross formation to block R1 from hitting S4 during the altercation. S4 does not recall R1 sustaining any injury during the incident. It was also reported that on 01/26/25, S7 recalls observing R1 with a bruise on R1’s upper inside left arm while bathing R1. S7 recalls R1 reporting that R1 was unsure of how the injury/bruise occurred. Additionally, according to R1’s Physicians Report dated 2/28/23 and R1s Individualized Service Plan dated 09/07/2022, R1 is prone to bruising due to prescribed medications. On 02/03/25 while LPA Vaid interviewed R1, LPA did not observe any visible bruising on R1s arm. The investigation did not reveal any evidence to support that staff physically abused R1 and/or that staff caused R1 injury which resulted in R1 sustaining a bruise.
Based on interviews conducted, observations made, and documents reviewed. Although the allegation 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 with Administrator Joel Niblett.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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