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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802426
Report Date: 11/08/2022
Date Signed: 11/08/2022 04:53:59 PM


Document Has Been Signed on 11/08/2022 04:53 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:BROOKDALE ALHAMBRAFACILITY NUMBER:
197802426
ADMINISTRATOR:WENTWORTH, NICOLE DFACILITY TYPE:
740
ADDRESS:1 E COMMONWEALTH AVETELEPHONE:
(626) 289-3871
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY:150CENSUS: 41DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Maddie Sievert, Resident CoordinatorTIME COMPLETED:
04:55 PM
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Licensing Program Analysts (LPAs) Cynthia Chan and Kimberly Ramirez conducted the unannounced annual inspection with the focus of the infection control domain. LPAs met with the Resident Coordinator, Maddie Sievert, who assisted with the visit. The facility is licensed for 150 adults ages 60 and over, of which 85 may be non-ambulatory. The non-ambulatory residents may not reside above the second floor. The hospice waiver is approved for 7 residents.

LPAs toured the facility and observed the following:
* The building consists of 3 floors. The ground floor is called the lobby, the second level is known as the 1st floor, and the third level is called the 2nd floor. The ground level consists of 3 common areas used as a game room, t.v. room, and an activity room. There are no resident rooms on the ground floor.
* Covid-19 signage are posted throughout the facility. Hand washing signs are posted in the bathrooms.
* Extra PPE supplies of at least 30 days are observed.
* The receptionist conducts the Covid-19 screening for all staff and visitors.
* The kitchen and dining rooms are located in the second level. LPA requested for Covid-19 signage to be posted in the dining room.
* Food supplies of 2 day perishable and a week of non-perishable are observed.
* Medications are centrally stored in the Medication Room located on the lobby floor. LPAs reviewed 4 residents' medications and medications are being administered as prescribed.
* The fire extinguishers were last inspected on 8/5/22.
* Staff were observed wearing a face mask.
* Per the Administrator, they have backup staff when needed and are following the strictest covid-19 guidance.

There are no deficiencies issued today. The exit interview was held. A copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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