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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 06/12/2023
Date Signed: 06/12/2023 07:20:54 PM


Document Has Been Signed on 06/12/2023 07:20 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:DEOSO, GEMMAFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 96DATE:
06/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Maya MnoyanTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 06/12/2023 at 1:300 Pm. LPA was met by Administrator Mnoyan and explained the pupose of the visit. Staff #9 (S9) assisted in tour of facility. Facility is licensed to serve residents over the age of 60 years old. The facility has a fire clearance for 130 non-ambulatory, 20 bedridden and is currently approved for 20 hospice residents. LPA requested and obtained a copy of Personnel Report, and Resident Roster.

Observations:

The facility is located on a residential street and is a single-story building. LPA toured physical plant and selected random residents rooms for inspection. LPA toured TV room, medication room, activities room, laundry room, theater room, and kitchen/dinning room area. LPA observed kitchen staff cleaning up kitchen after lunch service and observed several kitchen staff preparing dinner service. LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. Walk in freezer thermostat was observed to read 0 degrees F and walk in refrigerator thermostat was observed to read 40 degrees F. Dinning room area was observed to be clean and free from hazards. LPA observed dinning room tables to have seating charts. TV room, activities room, laundry room and theater room were all observed to be clean and free of hazards. LPA observed staff conducting a cooking class with residents in activities room. LPA selected rooms 116, 115, 120, 128, 136, 161 and 153 for inspection. Selected rooms all contained the required furnishings, linens and were observed to be clean with plenty of closet space. Water temperature in resident bathroom #153 was recorded as 109.7 degrees F. LPA observed and tested emergency call assist cord in resident bedroom # 120. Emergency assist cord was pulled at 3:05 pm and staff responded at 3:07 pm. LPA observed fist aid kit located in medication. LPA observed several fully charged fire extinguishers throughout the facility.

Due to time constraints, LPA will return at a later date to complete annual inspection. No deficiencies are being cited at this time. Exit interview was conducted with S9. A copy of this report will be emailed due to printer problems.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
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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