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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802426
Report Date: 11/22/2022
Date Signed: 11/22/2022 02:48:31 PM


Document Has Been Signed on 11/22/2022 02:48 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: 56DATE:
11/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jina Maleksarkissians, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit due to the inconsistencies found on documents during a complaint investigation. LPA met with Administrator, Jina Maleksarkissians, and explained the purpose of the visit.

LPA obtained documents pertaining to Resident #1 (R-1) during a complaint investigation control #28-AS-20211230090256. It was noted that R-1 was diagnosed with Alzheimer which was the reason for the one-on-one companion charge and discharge from the facility that took place in July to August of 2021. After review of documents, there was only one physician’s note dated on 7/29/21 which indicated “MMS 17/30 Alzheimer’s DZ”. The facility nurse also conducted a BIMS (Brief Interview for Mental Staus) test on 7/29/21 in which R-1 scored a 9. The August 2021 Medication Administration Record only mentioned mild cognitive impairment as one of the medical conditions. Facility progress notes did not indicate any observation of memory impairment for R-1. LPA confirmed with current Administrator Maleksarkissians there were no follow up Personal Care Plan nor Physician’s Report to confirm the diagnosis that was noted on 7/29/21. The family members also confirmed that R-1 is not diagnosed with Alzheimer’s disease.

Based on record review and interview, it is determined that the facility did not properly reappraise the resident. A deficiency is being cited on the LIC809D, in accordance to the California Code of Regulations, (Title 22, Division 6 and Chapter 8).



An exit interview was conducted. A copy of this report, appeal rights, and Plan of Corrections were provided to the Administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
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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Document Has Been Signed on 11/22/2022 02:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2022
Section Cited

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87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative... change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
This requirement is not met as evidenced by:
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Based on record review, a reappraisal was not done for Resident #1 for a change in condition which poses a potential health and safety 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: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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