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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802426
Report Date: 01/04/2022
Date Signed: 01/04/2022 02:08:53 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: 62DATE:
01/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Ryan Savala Maintenance supervisor TIME COMPLETED:
02:16 PM
NARRATIVE
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Licensed Program Analyst (LPA) Alberto Lopez made unannounced 10 day visit to investigate complaint. LPA asked and obtained facility staff and resident roster. LPA reviewed both rosters and observed that Maintenance supervisor Ryan Savala had not been associated to facility. Executive Director Tracey Holder stated that her office manager is the only one with access to Guardian and is out sick and could not provide evidence that staff was cleared and associated to facility at the time of visit, therefore $500 immediate civil penalty was issued. Ryan Savala has been employed since 06/01/2021.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 01/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2022
Section Cited

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Criminal Record Clearance-per section cited, all employees must be associated to the facility( if have previous clearance send transfer request). Staff Ryan Savala employed since 06/01/2021 was not associated to facility #197802426 Civil penalty of $500.00 was issued on 01/04/2022 .

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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2