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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802426
Report Date: 08/16/2021
Date Signed: 08/16/2021 04:52:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 63DATE:
08/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Tracey Holder, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced annual inspection with the focus of the infection control domain. LPA met with Tracey Holder, the Executive Director, and explained the purpose of the visit. The physical plant, a sample of the residents' medication, and food supplies were inspected.

LPA toured the facility with Liza Hong, the Health & Wellness Coordinator and observed the following:
* Signage are posted throughout the facility in English and with translations in Chinese. They consist of proper wearing of the masks, sneezing etiquettes, and social distancing.
* Elevators have signs posted that indicates a maximum of 2 people. Signage for Covid-19 are also posted inside the elevators and also in staff break room as reminders.
* Facility has a designated COVID-19 room on the 2nd floor to house any positive resident or any one showing any symptoms. The room has its own bathroom. Per Administrator, there are a total of 88 rooms and have additional spare rooms to move residents temporarily for quarantine.
* Sufficient amount of PPE supplies of at least 30 days were observed in the storage area located in the garage. Ample supply of disinfectants are also stored in the same area.
* The Dining Service Coordinator gave a tour of the kitchen. LPA observed the kitchen staff preparing and serving lunch in an orderly fashion. Sufficient supplies of perishable food for 2 days and non-perishables for a week were observed.
* LPA observed all the staff wearing a face mask and a housekeeper cleaning the common areas.
* Hot water temperature was measured between the required range of 105 to 120 degree F.
* The medication were reviewed for 6 residents and one of the residents' medication had a discrepancy, which appeared that one of the medication was given ahead of schedule.
Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.


SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BROOKDALE ALHAMBRA
FACILITY NUMBER: 197802426
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 residents' medication log which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/17/2021
Plan of Correction
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The Executive Director shall review the medication and MAR log for R1 to ensure that medication Nateglinide 120MG tablet is given as prescibed. The Executive Director shall submit the plan of action taken to resolve the discrepancy for this particular medication to LPA by POC due date 8/17/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021
LIC809 (FAS) - (06/04)
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