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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 12/18/2025
Date Signed: 12/18/2025 04:37:18 PM

Document Has Been Signed on 12/18/2025 04:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR/
DIRECTOR:		JACQUELINE CORTEZFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 150CENSUS: 147DATE:
12/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:Jacqueline Cortez, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management – Incident visit today to follow-up on two (2) Special Incident Reports (SIR) received by the department. LPA, met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained.

According to the first SIR, date of occurrence 10/19/2025, a staff member (Staff 3/S3) raised their voice and made an inappropriate comment to a resident (Resident 1/S1) during an encounter in which R1 requested help. R1, reported the incident to the Executive Director (Staff 1/S1) and Care Coordinator (Staff 2/S2).

According to interview with S1, S1 spoke to S3 to remind them that residents need to be always spoken to calmly and with respect. S1 stated that, S3 admitted to raising their voice and making inappropriate comment toward R1. S1 indicated that S1 and S2 assessed R1 after the incident and did not observe any injuries and R1 continued their normal routine the rest of the day.

S1 indicated that S1 talked to S3 on 10/31/25 regarding the incident, and a formal meeting and write-up regarding professional conduct and resident standards took place on 11/12/25. During this meeting, the written notice was discussed and provided by S2 to S3. Interview with S2 indicated that S3 has been taken off assignment of R1’s room and is not allowed to enter R1’s room at any time. S2 stated that they monitor the assignments and ensure that S3 does not interact with R1. Interview with R1 indicated that S3 is not coming into their room anymore and is glad that staff were proactive after R1 reported the incident.

****Continues to LIC 809-C****

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/18/2025
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According to second SIR, date of occurrence 10/25/25, staff member (Staff 4/S4), was observed by a resident (Resident 3/R3) raising their voice toward another resident (Resident 2/R2) as R3 walked down the hallways by R2’s room. SIR also reports that S4 was heard yelling at R2, “Leave me alone you lunatic or I will call the cops.”

Interview with S1 indicated that upon receiving the report from R3, S1 scheduled a meeting with S4 on 10/31/25, due to S4 working primarily during the night shift and S1 working during the day shift. S1 stated that during the meeting, S4 was suspended for further investigation. S1 took S4s statements and presented them to Human Resources. S1 indicated that they conducted the investigation and could not obtain any information from the alleged victim (R2) or other possible witnesses. S1 stated that they attempted to obtain more information from R2; however, R1 could not recall the incident. S1 indicated that due to insufficient evidence, S4 was reinstated to their job duties on 11/7/25; however, S4 still received counseling from S1 regarding expectations and protocols and working effectively with residents who may present behavioral challenges. S1 further indicated that S4 denied raising their voice at R2 and saying inappropriate statements. Interview conducted with R3 and R3 indicated that they heard S4 yelling loudly at R1 but could not remember what S4 said to R2 during the incident. LPA, attempted to interview R2, however, R2 was not responsive to LPA’s questions and stated, “I don’t remember that.”

During today’s visit, LPA did not observe any potential or immediate health and safety risks to residents in care. A citation is issued today per California Code of Regulations (Title 22). Exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report, 809-D and Appeal Rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2025 04:37 PM - It Cannot Be Edited


Created By: Mayra Cota On 12/18/2025 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2025
Section Cited
CCR
87468.1(a)(3)

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Personal Rights of Residents in All Facilities (a) Residents...shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...
This requirement was not met as evidenced by:
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Administrator provided proof of disciplinary written notice for violations of professional conduct and resident care standards. POC cleared at the time of visit.
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Interviews conducted with staff and resident indicate that staff member acknowledged raising their voice at resident and making inappropriate statement to resident in care.
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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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
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