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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802426
Report Date: 10/27/2022
Date Signed: 10/27/2022 05:32:46 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
12/30/2021 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211230090256
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: 59DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jina Maleksarkissians, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Resident sustained injury while in care.
Staff did not notify resident's authorized representative of incident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation on the allegations listed above. LPA met with Administrator, Jina Maleksarkissians, and explained the purpose of the visit.

The investigation consisted of the following:
On 1/4/22, LPA A. Lopez conducted the initial visit and collected the staff and resident rosters.
LPA Chan further investigated on these allegations and gathered documents pertaining to Resident #1 (R-1). On 10/27/22, LPA interviewed the Administrator and 4 Staff. Additional interviews were held via telephone on other days.

The investigation revealed the following:
Allegation - Resident sustained injury while in care. It was alleged that Resident #1 (R-1) had lesions about the size of a fist under both breasts.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20211230090256
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: BROOKDALE ALHAMBRA
FACILITY NUMBER: 197802426
VISIT DATE: 10/27/2022
NARRATIVE
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 Per interview with caregiver staff, Staff informed the Med Tech right away when R-1 appeared to have redness under the breasts which was discovered during a shower. LPA obtained copies of the skin integrity monitoring forms for R-1, it was noted R-1 had redness under the breast on 7/22/21. This redness was not reported to the Med tech/Wellness Director until 7/26/21. According to the facility progress notes, the Health and Wellness Director informed the physician on 7/27/21. The physician responded by indicating the patient has "severe B under the breast cellulitis" based on the photographs provided. Staff interviewed stated they would inform the Med Tech if they observe any changes right in a resident and the Med Tech will document and inform the physician. Based on this information gathered, the staff failed to report the skin condition timely which resulted with R-1 having breast cellulitis.

Allegation - Staff did not notify resident's authorized representative of incident. It was alleged that R-1's authorized representative was not informed of the lesions. Based on the incident mentioned above, R-1's authorized representative was not informed of the redness when it was observed by a staff on 7/22/21. Per R-1's Power of Attorney (POA), they were first contacted by the physician about the skin lesion under the breasts. According to the facility notes, it was documented that the POA was informed on 7/26/21 as opposed to 7/22/21 when the redness was first noted.

Based on record reviewed, 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 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with the Administrator Maleksarkissians. A copy of this report and appeal rights were given.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/30/2021 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211230090256

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: 59DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jina Malesarkissians, AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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9
Staff did not get resident's authorized representative's authorization for change in level of care for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation on the allegation listed above. LPA met with Administrator, Jina Malesarkissians, and explained the purpose of the visit.

The investigation consisted of the following:
On 1/4/22, LPA A. Lopez conducted the initial visit and collected the staff and resident rosters.
LPA Chan further investigated on these allegations and gathered documents pertaining to Resident #1 (R-1). On 10/27/22, LPA interviewed the Administrator and 4 Staff. Additional interviews were held via telephone on other days.

(Continue on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20211230090256
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: BROOKDALE ALHAMBRA
FACILITY NUMBER: 197802426
VISIT DATE: 10/27/2022
NARRATIVE
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The investigation revealed the following:
Allegation - Staff did not get resident's authorized representative's authorization for change in level of care for resident. It was alleged that the R-1 was ordered one on one care companion without asking R-1 authorized representative to authorize it. Per R-1's family member, the facility did not communicate that the one on one companion that R-1 obtained, had additional charges for diagnosis of Alzheimer's disease. LPA obtained a copy of the Physician's note dated 7/29/21 and the form indicated "MMS 17/30 Alzheimer's Dz". According to the facility note dated 7/29/21, the Health & Wellness Coordinator also conducted a BIMS (Brief Interview for Mental Status) assessment on the resident and received a score of 10/15. Executive Director (Tracey Holder) spoke with the authorized representative that R-1 needed the one-one-one companion, which representative verbalized understanding and agreed to the personal companion. Based on the information gathered, there was insufficient evidence to show that the resident's authorized representative was not informed of the charges and services.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Administrator Malesarkissians. A copy of this report along with the appeal rights were provided.


SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20211230090256
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: BROOKDALE ALHAMBRA
FACILITY NUMBER: 197802426
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2022
Section Cited
CCR
87413(a)(3)
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87413 Personnel - Operations (a) In each facility: (3) The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation or prejudice.
This requirement is not met as evidenced by:
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The administrator shall conduct an in-service training with staff regarding the importance of reporting observations. This training log shall be submitted to LPA by due date 11/3/22.
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Based on record review, the administrator did not ensure that the staff reports observation timely who poses a health and safety risk to resident in care.
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Type B
11/03/2022
Section Cited
CCR
87211(a)(1)(B)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency,,,(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident...(B) Any serious injury as...occurring while the resident is under facility supervision.
This requirement is not met as evidenced by:
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The Administrator shall ensure that any unusual incidents or changes in residents' conditions are reported timely to all parties. The administrator shall read the regulation and conduct an in-service training with the staff responsible for communicating with outside parties. The log shall be provided to LPA by 11/3/22.
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Based on record review, R-1's authorized representative was not made aware of the skin lesion when it first occurred which poses a personal rights risk to residents 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.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5