198603535-11-14-2022-28-AS-MVAO-CLVRF6-20221207115836

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 11/14/2022
Date Signed: 11/14/2022 01:54:24 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/09/2022 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221109142252

FACILITY NAME:	SANTA ANITA ASSISTED LIVING		FACILITY NUMBER:	198603535
ADMINISTRATOR:	DEOSO, GEMMA		FACILITY TYPE:	740
ADDRESS:	5600 GRACEWOOD AVENUE		TELEPHONE:	(626) 442-8410
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	150	CENSUS: 47	DATE:	11/14/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrative Assistant, William Woods		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff is unlawfully evicting resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced 10 day complaint visit to this facility and met with Administrative Assistant, William Woods and discuss the purpose of the visit.

The investigation consisted of: LPA Pena obtained copies of the staff/resident roster, Medical chart notes, incident reports, Resident #1 file, ID page, physician's report, IPP, Admissions agreement and resident appraisal.

Regarding allegation: Facility staff is unlawfully evicting resident. It was alleged that Resident #1 was not being accepted back to the facility after her hospital stay. R1 was ready to be discharged and able to return to the facility effective immediately with hospice care but S1 refused to take R1 back. According to RP, R1's brother arranged for a private hospice nurse to take care of R1 but S1 still refused her back. ***Report continued on LIC 9099-C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221109142252

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 198603535
	VISIT DATE: 11/14/2022

NARRATIVE

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The investigation revealed that the facility's Regional Nurse (S3) conducted the pre-appraisal and went to the hospital for re-assessment. S3 stated that R1 is now high risk and will need a higher level of care and that the facility will not be able to meet the residents' needs. S3 has reported this to S1 who in turn called W1 (R1's responsible party) to advise that the facility will not be able to take R1 back to the facility due to her medical condition. S1 spoke to W2 on the phone while W1 was on a speakerphone and explained the situation. S1 told W1 and W2 that R1's medical condition would need a higher level of care and the facility will not be able to meet her needs, hence they are not accepting her back to the facility. S1 stated that she did not provide an eviction notice to the family or CCLD. S2-S6 stated that they have not heard and unaware of any illegal evictions of residents in the facility. All staff interviewed stated that they do not know if anyone was evicted illegally. R2-R5 stated that they never had any issues or problems coming back to the facility after hospitalization. R2-R5 indicated that they have not heard and did not know if any resident was evicted illegally. R2-4 stated that they were hospitalized before and they came back to the facility. LPA reviewed R1's documents and observed that S3 has noted the medical charting of R1 stating her current medical condition and her level of care and needs will not be met by the facility. Although the facility conducted the pre-appraisal.re-assessment of R1 at the hospital to find out if R1 can come back to the facility, the eviction procedure was not followed. S1 should have issued an eviction notice and sent to CCLD within 5 days of finding out that R1's medical condition has changed to a higher level of care.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Administrative Assistant, William Woods along with the Appeals Rights.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221109142252

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 198603535
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 11/21/2022 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	87224 Eviction Procedures...(a) The licensee may evict a resident.. Thirty (30) days written notice to the resident is required....(4)If, after admission, has a need and a reappraisal has been conducted ... the licensee and the person who performs the reappraisal....not appropriate for the resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator will submit a copy of the written eviction notice and a signed statement that she read, reviewed and understood Title 22
	8 9 10 11 12 13 14	The Administrator did not issue/provide the required thirty (30) days eviction written notice to the family or the resident's responsible party and CCLD.	8 9 10 11 12 13 14	Regulations Division 6 Chapter 8 Article 04 Section 87224 Eviction Procedures to LPA on or before the POC due date.
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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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

LIC9099 (FAS) - (06/04)

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