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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 06/13/2023
Date Signed: 06/14/2023 11:59:22 AM


Document Has Been Signed on 06/14/2023 11:59 AM - 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:
06/13/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Maya MnoyanTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Continuation Visit on 06/13/2023 at 1:22pm, stemming from initial Annual Required Visit on 06/12/23. LPA was met by Administrator Mnoyan and explained the purpose of the visit.

Records Review:

LPA reviewed nine (9) staff personnel files, nine (9) resident files, and conducted nine (9) staff interviews. No deficiencies were cited during file review. LPA requested and obtained a copy of facility liability insurance. Due to time constraints, LPA will return to complete resident interviews at a later day. A copy of this report will be emailed to Administrator Mnoyan due to printer problems.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2023
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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