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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 06/17/2025
Date Signed: 06/17/2025 05:09:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/16/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250616120107
FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:JOEL NIBBLETFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 149DATE:
06/17/2025
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Jacqueline Cortez, Executive DirectorTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Staff are mismanaging resident's medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the allegation listed above. The purpose of the visit was explained to Executive Director Jacqueline Cortez.

The investigation consisted of: A physical plant tour of the interior and exterior was conducted, with special focus on medication room, residents' room signal system, kitchen food preparation/servings, and outdoor smoking areas. A total of nine (9) staff and 15 residents were interviewed. LPA reviewed and collected resident (R1 & R2's) file documents; which include Identification and Emergency Information, Physician's Report, Medication Administration Records, Care Plan, June 2025 food menus, alternative food menu, and kitchen resident diet list. LPA interviewed R1's pharmacist and Primary Care Physician's office representative.

*Narrative continues next page.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
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 4
Control Number 28-AS-20250616120107
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA ANITA ASSISTED LIVING
FACILITY NUMBER: 198603535
VISIT DATE: 06/17/2025
NARRATIVE
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Allegation: Staff are mismanaging resident's medication. The complaint alleges that resident (R1) did not receive blood pressure medications Furosemide 20 mg or Hydrochlorothiazide 25 mg for three days, and when med-techs were asked about the non-filled medications they had no idea why the medications were not filled. Resident (R1) stated in the past staff have given the resident another resident's medications, but the error was caught by the resident. A total of 15 residents were interviewed, of which 2 residents stated they have not been administered medications as directed by their physician. A total of nine staff were interviewed. Med-tech and Administration staff acknowledged that on June 14, 2025, resident (R1) ran out of the two aforementioned medications but did not contact R1's doctor or pharmacy until Saturday June 15, 2025. LPA called the facility pharmacy and R1's Primary Care Physician's office. The findings indicate that med-tech staff contacted the pharmacy and doctor until after the resident ran out of the medications. Based on record review of Medication Administration Records, med-tech staff did not communicate to Wellness Director or Executive Director that the pharmacy did not have a physician order for medications Furosemide 20 mg or Hydrochlorothiazide 25 mg. The pharmacist stated that on Sat. June 14, 2025 they delivered an emergency 3-day supply of medications. However, the QuickMar MAR states the medications were not dispensed, and notes indicate the medications are still pending. In addition, the pharmacy sent all the routine medications to the facility on June 11, 2025, with the exception of the two medications. Staff did not observe the two medications were not delivered. Therefore, there is sufficient evidence to corroborate the allegation.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D.

Exit interview was conducted with Executive Director Jacqueline Cortez. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20250616120107
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 06/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2025
Section Cited
CCR
87465(e)
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Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
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Executive Director agreed to submit 1. A written statement on medication administration protocols, and a plan that addresses the medications errors. 2. All med-tech staff shall obtain medication training from a medical professional 3. Physician orders for medications Furosemide 20 mg or Hydrochlorothiazide 25 mg.
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This requirement was not met evidenced by: Based on record review and interviews conducted, on June 14m, 2025 R1 ran out of 2 medications [ Furosemide 20 mg or Hydrochlorothiazide 25 mg]. Facility does not have a current physician order for the medications and they have not been filled as of today. This poses an immediate health and safety risk.
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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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4