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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 07/07/2023
Date Signed: 07/09/2023 12:38:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/09/2023 12:38 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
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: 110DATE:
07/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Maya MnoyanTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Continuation Visit on 07/7/2023 at 9:20Am, stemming from initial Annual Required Visit on 06/12/23 and Annual Continuation on 6/13/23. LPA was met by Staff #1 (S1) and explained the purpose of the visit.

LPA Ramirez conducted eight(8) residents interviews. LPA Ramirez requested facility liability insurance, facility will email proof of required liability insurance no later than 7/14/23. No deficiencies are being cited at this time. LPA Ramirez conducted exit interview and a copy of this report will be emailed due to printer problem.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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