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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802426
Report Date: 07/16/2021
Date Signed: 07/16/2021 01:35:37 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/08/2021 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210108154128
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: 70DATE:
07/16/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Tracey Holder, AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff did not respond to a resident’s call pendant timely.
Poor quality of food being served to residents.
Resident eloped from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the above allegations. LPA met with Administrator Tracey Holder and explained the purpose of the visit.

The investigation consisted of the following:

On 1/14/21, LPA Chan conducted the initial visit which consisted on a telephone interview with the Wellness Director and a video call to review the food supply and physical plant. 4 Residents were interviewed via Facetime on 4/12/21. On 5/11/21, LPA Chan held interviews with 4 Residents and 1 Staff at the facility. LPA interviewed an additional 3 Staff on 7/9/21.

(Continue on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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 4
Control Number 28-AS-20210108154128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/16/2021
NARRATIVE
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The investigation revealed the following:

Allegation - Staff did not respond to a resident’s call pendant timely. Administrator and Staff stated that staff would typically respond to resident’s call pendant between 5 – 10 minutes. When a resident presses the pendant, it pages the caregivers and they can see which room is calling along with the name of resident. Once the caregiver tends to the resident, he/she will reset the pendant. Although Staff reported that they usually respond right away, they also noted that sometimes they can take as long as 30 minutes to respond to the resident due to staff assisting another resident. 5 out of the 8 residents interviewed stated that it takes staff sometimes more than 15 minutes and as long as 30 minutes to respond. Some also feel that the facility has a shortage of caregivers.

Allegation – Poor quality of food being served to residents. Administrator Holder stated that she is not aware of any residents complaining about the quality of the food being served. LPA obtained the food menu and observed a variety of food listed. Staff stated that residents can choose either an American or Asian meal. They also have other alternatives available for lunch and dinner. Per Staff interviewed, 2 of them have heard residents complaining about the food being cold or meat is tough. Interviews with 4 out of the 8 residents indicated that the food sometimes tasted spoiled, meat was tough to chew, or vegetables were still cold.

Allegation - Resident eloped from the facility. Administrator Holder admitted that one of the residents had eloped from the facility back in January or February of 2020. Resident was discovered missing when the MedTech went to pass out medication to the resident. The resident was found and brought back to the community. Administrator stated at that time the resident was unable to leave the facility unassisted as indicated on the Physician’s Report. Another staff also confirmed that the resident had eloped from the facility without supervision. Per Administrator, the front desk has a list of residents who cannot leave the facility unsupervised and they try their best to monitor who arrives and leaves.

Based on LPA interviews conducted, 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 and Plan of Corrections were reviewed and developed with the Administrator, Tracey Holder. A copy of this report and appeal rights were discussed and left with Administrator whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Citations on this Visit Report are Under Appeal!

Control Number 28-AS-20210108154128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
07/23/2021
Section Cited
CCR
87411(a)
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87411 Personnel Requirements -General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance...
This requirement is not met as evidenced by:
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Administrator shall review the current roster to determine if there is sufficient staffing. Administrator will submit the LIC500 and a breakdown of staff for each department by POC due date 7/23/21.
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Based on interviews conducted, the licensee did not ensure there is adequate staffing to tend to residents' needs in a reasonable amount of time which poses a potential health and safety risk to residents in care.
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Under Appeal
Type B
07/23/2021
Section Cited
CCR
87411(a)
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87411 Personnel Requirements -General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance...
This requirement is not met as evidenced by:
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Administrator shall review the regulation code 87411 and residents' Physician's Report. Administrator shall submit the list of residents who cannot leave the facility unassisted and the plan to ensure those residents do not elope by POC due date 7/23/21.
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Based on interviews conducted, the licensee did not ensure that resident, who cannot leave unsupervised, does not elope from the facility 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Citations on this Visit Report are Under Appeal!

Control Number 28-AS-20210108154128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
07/23/2021
Section Cited
CCR
87555(b)(8)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality.

This requirement is not met as evidenced by:
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Administrator shall review the food quality and ask residents if there are any issues with the food quality. Administrator shall submit a statement after communicating with the residents by POC due date 7/23/21.
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Based on interviews conducted, the licensee did not ensure that the food is of good quality which poses a potential health, safety, and 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4