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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 12/06/2024
Date Signed: 12/20/2024 09:33:48 AM

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
08/15/2024 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240815132940
FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:MAYA S MNOYANFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 143DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Aaron KhodorkovskyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are mismanaging resident's medications.
INVESTIGATION FINDINGS:
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*** This licensing report issued on today’s visit, 12/06/2024 supersedes that licensing report dated 10/11/2024, LPA Vaid is reissuing the report and citations, however, the investigation findings will remain the same***

Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the allegation listed above to reissue the report and to reissue citation for the investigated complaint findings.

Regarding the allegation: Staff are mismanaging residents’ medication. It is alleged that staff give residents day and evening medication together. The investigation consisted of interviews with staff and residents, including resident #20 (R#20) and review of R#20 Medication Administration Record. The investigation revealed, on 08/08/24, staff #21 gave R#20 the afternoon blood pressure (name medication) a dosage of 10 mg in the morning. This medication error was observed by Staff 10 (S10) during the medication audit conducted during the Med Tech staff shift change. The protocol for shift change is for each med-tech to audit the medications in the medication carts before starting their shift. S10 reported the medication error former administrator Maya Mnoyan, who contacted R#20 physician and placed S#21 on suspension during the facility’s internal investigation. Based upon the facility’s investigation S#21 was terminated from employment. Therefore, S#21 did not properly administer R#20 blood pressure medications.
Substantiated
Estimated Days of Completion: 0
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
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 16
Control Number 28-AS-20240815132940
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: 12/06/2024
NARRATIVE
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Based on interviews conducted, and records collected and reviewed the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Deficiencies are being cited according to California Cade of Regulations, Title 22.

Citation is on 9099-D page.

Exit interview was conducted and copy of report and appeals were given to the Administrator Aaron Khodorkovsky.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 16
Control Number 28-AS-20240815132940
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: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2024
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care.(c)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
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Administrator will provide staff with medication administering training by 12/13/24.
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Title 22, Division 6
Chapter 8
This requirement was not met as evidenced by: On 08/08/24, staff #21 gave R#20 the afternoon blood pressure medication, a dosage of 10 mg in the morning.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 16
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
08/15/2024 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240815132940

FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:MAYA S MNOYANFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 143DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Aaron KhodorkovskyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are overdosing residents.
Staff are administering unprescribed medications to residents.
Staff do not answer residents’ call button in a timely manner.
Staff do not ensure residents’ showering needs are being met.
Staff do not ensure the facility has an adequate food supply.
Staff do not ensure residents attend scheduled medical appointments.
Staff do not ensure residents’ air conditioner is in good repair.
INVESTIGATION FINDINGS:
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*** This licensing report issued on today’s visit, 12/06/2024 supersedes that licensing report dated 10/11/2024, LPA Vaid is reissuing the report and citations, however, the investigation findings will remain the same***
Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the allegation listed above to reissue the report and to reissue citation for the investigated complaint findings.

Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit regarding the above allegations. LPA conducted the initial complaint visit on 08/19/2024, this is a residential care facility for the elderly, a housing arrangement for persons, 60 years old and over. 24-hour non-medical care and supervision is provided. During today’s visit LPA met with Administrator Khodorkovsky and explained the purpose of today’s visit. On today’s visit LPA Vaid conducted a physical plant tour with Admin Khodorkovsky and did not observe any health and safety concerns. Staff and home health agencies were observed assisting residents. cont 9099C...
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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 16
Control Number 28-AS-20240815132940
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: 12/06/2024
NARRATIVE
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Regarding allegation: Staff are overdosing residents. It was alleged that staff are overmedicating residents with a Narcotic called Avitan used to treat adults with insomnia caused by anxiety and can cause drowsiness. Staff S1-S14 interviewed denied the allegation. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed med-tech staff overmedicating any of the residents. The Med-techs have stated that the medication is administered as prescribed as needed. Each residents’ medication that is administered is logged into the MARs. The medication cart and the medication room is audited each month, by management. LPA's review of five (5) random residents’ medication, and medication administration records, observed medication to be administered as prescribed by physician’s orders. All medications are accounted, as shown in the MARs log, LPA performed pill count of medications in the bubble packs. LPA reviewed residents that are prescribed Avitan, the MARs indicate that the Avitan has been administered sparingly, administered when needed to specific residents with attributing health conditions. Resident R1-R20 interviewed were unable to corroborate the allegation. Based upon records review and interviews conducted, the findings indicate that, 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.

Regarding the allegation: Staff are administering unprescribed medications to residents. It is alleged that the staff had administered unprescribed medications to the residents who misbehave during the night, by logging incorrect information of medication administered. Covering up the pill count. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the medication technician staff administer unprescribed medication to residents. The Med-techs stated that medication is administered as prescribed. The narcotics log used to record time, date and dosage administered to the resident(s). The narcotics medication(s) are audited randomly each month for each resident using medications containing heavy narcotics. Medication audits are performed monthly by the Wellness Director to ensure medications are being administered as prescribed by the physician orders, constant communications with the pharmacy via eMARs (electronic medication administered records) ensure consistent supply of all medications continues. LPA's review of five (5) random resident medication, and medication administration records, shows that medication appears to be administered as prescribed by physician orders and pharmacy orders. Resident R1-R20 interviewed were unable to corroborate the allegation. Based upon records review and interviews conducted, the findings indicate that, 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. con't 9099C...
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
Page: 13 of 16
Control Number 28-AS-20240815132940
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: 12/06/2024
NARRATIVE
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Regarding the allegation: Staff do not answer the resident’s call button in a timely manner. It is alleged that staff are not answering the call button in a timely manner when residents call for assistance. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the staff not answering the call button switchboard in a timely manner. LPA observed a call come into the office by a resident asking for assistance, within 1-2 minutes a caregiver answered the office to acknowledge the call being handled, the call was answered by a staff person from the resident’s room. Residents R1-R15 interviewed stated that the caregivers come within 2-3 minutes after call is made on the residents’ call box, someone always answers. Based upon observations made and interviews conducted, the findings indicate that, 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.

Regarding the allegation: Staff do not ensure residents’ showering needs are being met. It is alleged that staff are not ensuring residents showering needs are being met. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. Caregiver staff and direct person staff(DSP) interviewed state, the caregivers staff assist the Home Health Aides with bathing the residents 2-3 times per week as noted in the resident’s needs/services plan. When residents refuse bathing, a note is made for bath refusal in the ADL (assisted daily living) clinical notes. Basic ADLs like brushing teeth, washing face, and combing hair, dressing is applied daily. Fifteen (15) out of fifteen (15) residents interviewed stated the staff gives baths twice a week, some residents stated they were given bathes three times a week by the home health agencies, the caregiver staff provides the rest. Based upon records review and interviews conducted, the findings indicate that, 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.

Con't 9099C...
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 14 of 16
Control Number 28-AS-20240815132940
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: 12/06/2024
NARRATIVE
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Regarding the allegation: Staff do not ensure facility has adequate food supply. It is alleged that the staff is not ensuring adequate food supply for residents. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. Kitchen staff interviewed state, grocery list is planned and ordered on Sunday and Wednesday for delivery of food on Monday and on Thursday. The kitchen was observed to have enough foods to feed all the residents, during tour of the kitchen LPA observed delivery being made, many boxes and bags of fruit and vegetable along with canned and dry food items being delivered. Fifteen (15) out of fifteen (15) residents interviewed state they like the food served and have never experienced food shortage at the facility. Based upon records review and interviews conducted, the findings indicate that, 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.

Regarding the allegation: Staff do not ensure residents attend scheduled medical appointments. It is alleged that a staff person is cancelling residents’ medical and other important appointments. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. The residents with medical appointments, relay information to the caregivers and the care coordinator, who then logs in the appointments in the transportation log to ensure the drivers are aware of resident’s appointments. The protocol for the appointment scheduling is verified by the care coordinator to ensure all necessary paperwork and insurance paperwork is ready for the residents. Fifteen (15) out of fifteen (15) residents interviewed stated they are happy with the transportation protocols and have not had any problems with keeping their appointments. Based upon records review and interviews conducted, the findings indicate that, 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.


con't 9099C....
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 15 of 16
Control Number 28-AS-20240815132940
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: 12/06/2024
NARRATIVE
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Regarding the allegation: Staff do not ensure residents’ air conditioner is in good repair. It is alleged that the staff is not ensuring that the air conditioner system is not in good repair. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. The air conditioner units are maintained by the maintenance staff, all air-conditioner systems are operational. When a unit breaks down or needs service, a work order is issued for maintenance to repair, repairs are handled within 24 hours unless parts are needed ordering. Accommodations for the residents are made if repair takes longer than anticipated. Regarding maintenance all work orders are logged to ensure completion of the projects in timely manner. Fifteen (15) out of fifteen (15) residents interviewed stated they have no concerns of the A/C units, staff is always fixing and are repairing things around the facility. Based upon records review and interviews conducted, the findings indicate that, 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.

LPA did not observe any Health and Safety concerns during the visit, an exit interview was held and copy of this report was given to the Administrator Aaron Khodorksky.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 16 of 16