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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 08/28/2025
Date Signed: 08/28/2025 03:06:07 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
05/30/2025 and conducted by Evaluator Mayra Cota
COMPLAINT CONTROL NUMBER: 28-AS-20250530112753
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: 147DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Jacqueline Cortez, Executive DirectorTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff are mismanaging resident's medications.
INVESTIGATION FINDINGS:
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***This is a corrected version of the original report dated 8/11/25. The purpose of the report is to correct a deficiency issued in error on the LIC 9099-D (section 87465 (b)(3)) which will be dismissed. On today's visit, LPA is issuing a citation under section 87465(c)(3)***

Licensing Program Analyst, Mayra Cota, conducted a subsequent visit to investigate the allegation above. LPA met with Jacqueline Cortez, Exective Director and the reason for the visit was explained.

Itnitial 10-day visit was conducted on 6/5/25 by LPA Cota. During initial visit, LPA, obtained a copy of the staff and resident rosters, conducted medication review and obtained medication records for Residents 1-8 (R1-R8). Interviews were also conducted with Staff 1-8 (S1-S8).
During today's visit, LPA obtained copies of staff and resident rosters, toured common areas of the facility, interviewed Resident 1 - Resident 8 (R1-R8) and delivered findings.
***Continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
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 3
Control Number 28-AS-20250530112753
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: 08/28/2025
NARRATIVE
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The investigation revealed the following:
Regarding: Staff are mismanaging resident's medications.

It is alleged that Medication Administration Record (MAR) had multiple medication errors regarding a medication dose for pain relief. The medication in reference to is Oxycodone. It was reported that medication error is on file at RCFE.

QuckMAR reviewed for R1 indicated, medication administration was not recorded on May 2, 2025, for the 2:00 p.m. dose, May 4, 2025, for the 2:00 p.m. dose and May 5, 2025, for the 8:00 p.m. dose of the PRN Oxycodone-Acetaminophen 325 mg tablets. The three days are missing initials from administering staff. Interview with S2 indicated, staff did not "click" on the days which are missing initials, which would indicate that medication was administered correctly to resident. S2 further indicated, most likely, R1 did receive the medication on the days the initials are missing; however, the missing initials on R1's QuickMar are errors made by med-techs for not "clicking" on those specific days after "popping" the medication and giving it to R1. S2 further indicated, R1 would not miss doses of this particular medication because R1 has chronic pain and the medication helps alleviate it. S2-S8 acknowledged during interviews that sometimes, med-techs forget to "click" on the QuickMar after administering medication to residents to indicate that it was provided. Staff also indicated, QuickMar, at times, has connectivity issues and therefore, a "back-up" paper MAR is kept to document the administration of medication like Oxycodone for those residents who are prescribed to take it. At the time of visit, R1's paper MAR for May 2025, was not available for review for the fore mentioned dates.
Interview with R1 indicated, staff are administering all their medication correctly and in a timely manner. R1 further stated, med-techs have not missed any dosages of their medication, especially their PRN Oxycodone because they suffer from chronic back pain and therefore, they need it to ease their pain. Interviews with R2-R8 indicated, they have no concerns regarding how the facility manages their medication. It has been found that there is sufficient evidence to corroborate the allegation.

Based on record review and staff and resident interviews, the facility was unable to provide a record of each dose including date and time the PRN medication was taken, the dosage taken, and the resident's response for May 2, 4 and 5, 2025 for R1. The preponderance of evidence standard has been met, therefore the above allegation is substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099- D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 28-AS-20250530112753
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: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2025
Section Cited
CCR
87465(c)(3)
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Incidental Medical and Dental Care 87465(c)(3): (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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
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Licensee will ensure med-techs receive additional training regarding proper documentation of medication administration, documenting and reporting documentation errors and notifying physicians of errors by POC due date. Licensee will send training sign-in log and an agenda stating the topics discussed with staff.
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This requirement was not met as evidenced by: at the time of visit on 8/11/25, the facility was unable to provide a record of each dose including date and time the PRN medication was taken, the dosage taken, and teh resident's response for May 2, 4 and 5, 2025 for R1.
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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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3