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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603597
Report Date: 10/08/2024
Date Signed: 10/08/2024 02:24:32 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
09/04/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240904092531
FACILITY NAME:SAVANT OF ALHAMBRAFACILITY NUMBER:
198603597
ADMINISTRATOR:PHAM, LISAFACILITY TYPE:
740
ADDRESS:1 E COMMONWEALTH AVETELEPHONE:
(626) 289-3871
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY:176CENSUS: 132DATE:
10/08/2024
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Lisa Pham, Administrator TIME COMPLETED:
02:57 PM
ALLEGATION(S):
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Staff did not ensure correct medications were dispensed to resident
Staff did not ensure medications were dispensed in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alberto Lopez made subsequent visit to complete investigation and deliver findings. LPA met with Administrator Lisa Pham and discussed the purpose of the visit.

On 09/20/2024, LPA made visit and met with Business Manager Ruby Andrade. During this visit LPA interviewed four (4) staff, one (1) witness and eight (8) residents, LPA reviewed R1 file, R1 MAR for month of July 2024, reviewed and obtained staff and resident rosters, controlled substance medication record for July 1 – July 25, 2024 for R1, copy of prescription for R1, San Gabriel Valley Medical Center Discharge paperwork for R1 dated 07/27/2024, 8-hour medication training certificates for staff dated 08/02/2024, SIR dated 7/27/2024, shower refusal log for R1,LIC602, and Admissions agreement.

On 10/08/2024 LPA interviewed S7 and S8 and attempted to interview S5. S5 stated she was unable to answer any question due to being too busy and LPA was unable to interview S5.
(continued on 9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
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 6
Control Number 28-AS-20240904092531
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: SAVANT OF ALHAMBRA
FACILITY NUMBER: 198603597
VISIT DATE: 10/08/2024
NARRATIVE
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(continued from 9099)
The investigation revealed:

Allegation: Staff did not ensure correct medications were dispensed to resident. It is alleged that S5 gave R1 another resident's medication.

According to SIR dated 07/27/2024, R1 was administered incorrect medication on 7/26/2024 at approximately 9:00 PM
LPA Interviewed eight (8) staff and six (6) of eight (8) staff corroborated the allegation. One staff did not know and could not answer and S5 could not answer LPA questions during phone contact and stated S5 was too busy. S1, S2, S3, S6, S7, and S8 admitted the medication error and One (1) of eight (8) residents was able to corroborate the allegation. W#1 who is family member also corroborated the allegation. On 7/26/2024 at approximately 9:00 PM, S5 provided the wrong medication to R1. The error occurred because S5 mistook one resident for another because both residents shared the same last name. There is enough evidence to substantiate this allegation

Allegation: Staff did not ensure medications were dispensed in a timely manner. It is alleged that one staff forgot to provided medications to resident at one night.

LPA interviewed eight (8) staff and six (6) of (8) staff denied the allegation. S3 admitted that this occurred. S8 who was responsible to administer medications to resident one night stated S8 forgot and called niece immediately to notify her and immediately administered the medication that night. Medication were administered late on at least one night according to S8 statement. LPA interviewed Eight (8) residents and seven (7) of (8) residents could not corroborate the allegation. There is enough evidence to substantiate this allegation.

The facility admitted the errors and stated they took corrective action that included additional training of staff.

Based on LPA's record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation are SUBSTANTIATED.

Exit interview and copy of report, 9099-D and appeal rights provided to administrator Lisa Pham.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20240904092531
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: SAVANT OF ALHAMBRA
FACILITY NUMBER: 198603597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/09/2024
Section Cited
CCR
87465(c)(2)
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87465(c)(2) (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 was not met as evidenced by:
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Facility will complete an incident report documenting the medication error. The report will include if the primary physician has been notified of the error. Administrator shall ensure all med-tech staff received additional training. Sign-in sheet and training material will be emailed to LPA by the POC due date. Administrator will include in writing the steps taken to avoid future medication errors by POC due date.
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On July 26th 2024, R1 was given medication that belonged to another resident by mistake
which poses an immediate Health, Safety, or Personal Rights risk to persons 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/04/2024 and conducted by Evaluator Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20240904092531

FACILITY NAME:SAVANT OF ALHAMBRAFACILITY NUMBER:
198603597
ADMINISTRATOR:PHAM, LISAFACILITY TYPE:
740
ADDRESS:1 E COMMONWEALTH AVETELEPHONE:
(626) 289-3871
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY:176CENSUS: DATE:
10/08/2024
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Lisa Pham, Administrator TIME COMPLETED:
02:57 PM
ALLEGATION(S):
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Staff does not ensure residents medication records are properly maintained
Staff did not ensure residents were provided with bathing service
INVESTIGATION FINDINGS:
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Allegation: Staff does not ensure residents medication records are properly maintained. it is alleged that facility is not keeping proper medication records.

The investigation revealed: LPA interviewed eight (8) staff and eight (8) of eight staff denied the allegations. All staff stated they keep accurate records. LPA reviewed medication records for R1 and they were accurate at the time of visit. LPA interviewed eight (8) residents and seven (7) of eight (8) residents could not corroborates the allegations. There is not enough evidence to substantiate this allegation.

Allegation: Staff did not ensure residents were provided with bathing service. It is alleged that bathing service for R1 was not provided as stated in the admission agreement which is two (2) times per week.

The investigation revealed: LPA Interviewed eight (8) staff and eight (8) of eight (8) staff denied the allegation. (Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20240904092531
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: SAVANT OF ALHAMBRA
FACILITY NUMBER: 198603597
VISIT DATE: 10/08/2024
NARRATIVE
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(continued from 9099)

Some staff stated that R1 refused bathing service. LPA interviewed eight (8) residents and seven (7) of eight (8) residents could not corroborate the allegations. LPA reviewed and obtained bathing log documentation for R1 that shows that resident refused bathing services on July 26, 30, 2024, and on August 2,6,9, 2024 for reasons of not feeling well to dizziness.


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

Exit interview was conducted, a copy of this report and Appeal Rights were provided to Administrator Lisa Pham.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 28-AS-20240904092531
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: SAVANT OF ALHAMBRA
FACILITY NUMBER: 198603597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/09/2024
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(5) The licensee shall assist residents with self administered medications as needed.

This requirement is not met as evidenced by:
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Administrator shall provide additional training to all Staff responsible for medication assistance and provide proof to the department by the POC date.
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Resident #1 did not receive their medication on at least one night on time because S8 stated S8 forgot which poses an immediate Health, Safety, or Personal Rights risk to persons 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6