SANTA ANITA ASSISTED LIVING

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: LPAs observed signal/auditory devices on (4) exit doors. Staff indicated that the facility recently installed the auditory devices; however, they are non-operational. LPAs observed the auditory devices to be non-operational during visit.

Official plan of correction

Licensee/Administrator will ensure that the auditory/signal system is working at all times. Licensee/Administrator will email proof of staff in-service and proof that the entire building's auditory/signal system and pendants were tested and are receiving the page within facility protocols response time by POC due date.

Deadline recorded: Sep 4, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the licensee did not comply with the section cited above in (2) out of (10) resident rooms inspected had loose shower grab bars. Shower side grab bar in room #143 and shower grab bar above faucet in room #112 are loose. Grabs bars observed not properly bolted to the wall, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2026 Plan of Correction Licensee/Director will send LPA photos of the repairs for the grab bars by POC due date.

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observation on 7/17/25, the licensee did not comply with the section cited above in that several live cockroaches were observed in the dishwashing area of the kitchen during visit, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will contract services for pest control to alleviate the presence of cockroaches. Licensee shall closely monitor the cockroach issue and have the pest control company treat the facility. Licensee will send LPA, invoice of pest control services by POC due date. POC is cleared.

Deadline recorded: Jul 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

87303(a)(1) Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by: during inspection of (2) resident dining rooms, missing floor tiles/panels were observed in the main dining room by kitchen door under table and between doorway to secondary resident dining room. Both affected areas have lifted edges and grime accumulated on the surface creating a trip hazard, which poses a potential health and safety risk for persons in care.

Official plan of correction

Licensee will replace missing floor tiles/panels in both areas of the dining rooms and will send LPA photos of the repairs/corrections by POC due date.

Deadline recorded: Mar 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having the warning sign posted by the kitchen dishwashing sink for water delivered at 125 degrees F. during inspection which poses a potential safety risk for kitchen staff/empoyees.

Official plan of correction

Licensee will post the warning sign above or by the kitchen dishwashing sink by POC due date and send LPA a photo as proof.

Deadline recorded: Feb 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(29)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above in that two dry food containers for rice and oatmeal had broken lids and content was exposed during time of visit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will replace broken dry food containers to ensure lids are tight-fitting by the POC due date. Licensee will send a copy of purchased containers and photo of the replaced containers along with their lids.

Deadline recorded: Feb 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

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: Interviews conducted with staff and resident indicate that staff member acknowledged raising their voice at resident and making inappropriate statement to resident in care.

Official plan of correction

Administrator provided proof of disciplinary written notice for violations of professional conduct and resident care standards. POC cleared at the time of visit.

Deadline recorded: Dec 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews conducted and documents reviewed, licensee did not ensure that R1 received their medication at the correct times and thus, received excessive medication within a six-hour period. Medication was administered too soon between doses which poses an immediate risk to the health, safety, or personal rights to residents in care.

Official plan of correction

Administrator will provide medication training to med-tech staff which will include shadowing and will submit a copy of training log, topic, description of training, and duration of training by POC due date.

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not having the warning sign posted by the kitchen dishwashing sink for water delivered at 125 degrees F. during inspection, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2025 Plan of Correction Licensee will post the warning sign above or by the kitchen dishwashing sink by POC due date and send LPA a photo as proof.

Official classification

Type A

Official code

87303(e)(4)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that grab bar in shower breaking off the wall in resident bathroom, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2025 Plan of Correction Licensee will repair broken grab bar in resident bedroom by POC due date and send LPA a photo of the repair.

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that several live cockroaches were observed in the dishwashing area of the kitchen during visit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2025 Plan of Correction Licensee will contract services for pest control to alleviate the presence of cockroaches. Licensee shall closely monitor the cockroach issue and have the pest control company treat the facility. Licensee will send LPA, invoice of pest control services by POC due date.

Official classification

Type A

Official code

87555(b)(29)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above in that two dry food containers for rice and oatmeal had broken lids and content was exposed during time of visit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2025 Plan of Correction Licensee will replace broken dry food containers to ensure lids are tight-fitting by the POC due date. Licensee will send a copy of purchased containers and photo of the replaced containers along with their lids.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in that LPA observed a medication present in the bubble pack and not given to a resident which should have been administered on 7/8/25 to R1 (Famotidine 20 mg). Staff interview indicated, they forgot to give the resident (R1) the medication at the time it was due for administration. Also, an evening medication was administered too early on 7/17/25 to R4. LPA observed missing medication in the evening slot for 7/17/25 (Quetiapine Fumarate 25 mg), which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2026 Plan of Correction Licensee will contact the primary physician to notify them of the missed medication. Licensee will also document plan to prevent medication errors. Plan is due by POC due date. Medication training for staff will be conducted and is due by: 7/31/25. LIcense will send training log with personnel in attendance by day of training.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) 87211 Reporting Requirements: (a) Each licensee shall furnish..: (1)A written report shall be submitted to the licensing agency... within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident.... This requirement is not met as evidence by: LPA observed that the facility did not submit an incident report for Resident #1 (R1) who fell on 04/25/2025 and sustained an injury which poses a potential health and safety risk to the residents in care.

Official plan of correction

Administrator agreed to conduct in-service training for staff and create the incident report for R1 and submit it to CCL/LPA by POC due date.

Deadline recorded: May 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.

Official plan of correction

This requirement was not met as evidence by: R1 was asked to sign a document violating thier right to leave the facility freely, interfere and retaliate against R1 for exercising their rights. Licensee will retrain staff on this regulation and send proof of re-training by 6/28/24. Licensee will recind this notice by 6/17/24 and send proof to LPA Ramirez via email.

Deadline recorded: Jun 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(b)(13)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. This requirement is not met as evidence by: R1 physican ordered R1 have blood sugar monitored and recorded 3x a day, R8 physican ordered R8 have blood pressure monitored and recorded. Staff only recorded 1 day of R1's blood sugar and no proof of monitoring or logging of R8 blood pressure.

Official plan of correction

Licensee will certify plan to re-train staff on providing assistance in meeting medical needs of residents and following the physicans orders in regards to medical needs. Licensee will provide proof of staff training attendance sheet by 7/25/23. *No further action required*

Deadline recorded: Sep 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Resident accommodation carpet is disrepair and not clean. Room 129 bathroom tub and floor was observed to be dirty.

Official plan of correction

Licensee will replace carpet or remove stains. Licensee will send picture proof of replaced carpet or invoice of professional carpet cleaning services for room 129. Licensee had staff clean bathroom during visit. No further action required for bathroom correction.

Deadline recorded: Sep 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)(2)

Regulation authority

CCR

What the official deficiency says

87465(a)(1) Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (2)The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidence by: R1 physican ordered R1 have blood sugar monitored and recorded 3x a day, R8 physican ordered R8 have blood pressure monitored and recorded. Facility staff only recorded 1 day of R1's blood sugar and no proof of monitoring or logging of R8 blood pressure.

Official plan of correction

Licensee will certify plan to re-train staff on providing assistance in meeting medical needs of residents and following the physicans orders in regards to medical needs. Licensee will provide proof of staff training attendance sheet by 7/25/23.

Deadline recorded: Jul 18, 2023. A deadline is not proof that correction was completed.