198603535-7-18-2025-28-AS-FFIS-DK9VSM-20250805164144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 07/18/2025
Date Signed: 07/18/2025 05:44:21 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
06/13/2025 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250613170613

FACILITY NAME:	SANTA ANITA ASSISTED LIVING		FACILITY NUMBER:	198603535
ADMINISTRATOR:	JOEL NIBBLET		FACILITY TYPE:	740
ADDRESS:	5600 GRACEWOOD AVENUE		TELEPHONE:	(626) 442-8410
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	150	CENSUS: 146	DATE:	07/18/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Alisa Dean, Business Office Manager		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Resident missed medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation regarding the allegations listed above. LPA met with Alisa Dean, the Business Office Manager, and explained the purpose of the visit.

The investigation consisted of the following:
On 6/19/25, LPA Chan conducted the initial visit and obtained copies of the resident and staff rosters. LPA toured the kitchen, dining room, and medication room. Interviews were held with the administrator, Staff #1 - #5, and Residents #1 - #5. During the visit today, LPA interviewed an additional four Staff and five Residents and reviewed medications for residents.

(continue on LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

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

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20250613170613

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: 07/18/2025

NARRATIVE

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The investigation revealed the following:
Allegation - Resident missed medication. It is alleged that residents have missed medications due to medications not being refilled on time. LPA interviewed Staff and Residents for this allegation. Three of the med techs stated that residents may have missed their medications due to pending physician’s approval for the refills. Staff stated they would order refills about 7-10 days prior to medications running out. Staff noted that self-managed medications are refilled by the residents themselves. Residents interviewed stated that the facility manages their medications and do not believe they have missed any. LPA reviewed medications for ten residents. Two out of the ten residents have at least one of their medications for which they have a physician’s order to self-manage. Staff stated they would assist with ordering refills if residents asked. LPA reviewed Resident #3’s medications with the medication administration record (MAR). It appeared that the medication Alendronate Sodium 70 MG tablet was prescribed once a week in June 2025 and was indicated on the MAR log with the staff’s initials. However, the medication could not be located in the med room/cart. LPA confirmed with the staff that the medication was not available in June because the refill has not been obtained by the family member. There were no staff notes available for this medication to follow up on a refill.
Based on LPA observation and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. A copy of this report, a plan of correction, and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20250613170613

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: 07/18/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/19/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall ensure medications are refilled timely and that residents do not miss any dosage. An in-service training for medication staff shall be conducted and the log to be submitted to LPA by 7/19/25.
	8 9 10 11 12 13 14	Based on record review, Resident #3 did not take the medication Alendronate Sodium 70 MG once a week in June which poses an immediate health and safety risk to resident in care.	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: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
06/13/2025 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250613170613

FACILITY NAME:	SANTA ANITA ASSISTED LIVING		FACILITY NUMBER:	198603535
ADMINISTRATOR:	JOEL NIBBLET		FACILITY TYPE:	740
ADDRESS:	5600 GRACEWOOD AVENUE		TELEPHONE:	(626) 442-8410
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	150	CENSUS: 146	DATE:	07/18/2025
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Alisa Dean, Business Office Manager		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff are retaliating against resident for filing complaints with CCLD.
Staff spits in resident's food.
Staff is unsanitary when handling food.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20250613170613

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: 07/18/2025

NARRATIVE

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The administrator and staff stated they do not retaliate and have not observed any staff mistreat residents for filing complaints. The alleged staff denied showing any form of retaliation against the resident who contacted the police and alleged that the staff pushed the resident. LPA interviewed ten residents and nine out of ten do not feel that staff retaliate against anybody filing complaints. The majority of the residents feel that the staff are respectful and assist them when needed.

Allegation - Staff spits in the resident's food. LPA interviewed the administrator and staff. All the staff denied spitting in the resident’s food, and they have not seen any staff do so. Kitchen staff interviewed stated they treat residents with respect and would not do such a thing. LPA interviewed ten residents, and nine out of ten have not seen any staff spit in their food.

Allegation - Staff is unsanitary when handling food. It is alleged that a staff does not change their gloves after wiping their nose or face and will continue serving the food with the contaminated gloves. It is also alleged that residents have been getting sick due to salads containing mayonnaise being left out of the refrigerator for 4-5 hours until they are served to residents. LPA conducted interviews with the administrator, kitchen staff, and residents. The kitchen staff stated they have received training on the appropriate handling of food and etiquette toward residents. Staff stated they are required to wear hair nets and gloves while preparing and serving food. When they need to sneeze, wipe their noses or faces, they will use a tissue or another part of their arm. Afterwards, they will discard the gloves, wash their hands, and put on a new pair. Staff have not witnessed other staff using a contaminated glove and serving food to residents. Staff also do not prepare food many hours ahead of mealtime and leave them unrefrigerated. Nine out of the ten residents interviewed stated that they have not seen staff being unsanitary or have not gotten ill from food served at the facility.

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.

An exit interview was conducted with A. Dean. A copy of this report, along with the appeal rights, was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025

LIC9099 (FAS) - (06/04)

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