198603597-6-10-2024-28-AS-ALOZ-D64W2V-20240610165457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603597
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:55:06 PM

Document Has Been Signed on 06/10/2024 04:55 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:	ALHAMBRA SENIOR VILLA		FACILITY NUMBER:	198603597
ADMINISTRATOR/ DIRECTOR:	PHAM, LISA		FACILITY TYPE:	740
ADDRESS:	1 E COMMONWEALTH AVE		TELEPHONE:	(626) 289-3871
CITY:	ALHAMBRA	STATE: CA	ZIP CODE:	91801
CAPACITY: 176		CENSUS: 83	DATE:	06/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:44 AM
MET WITH:	Lisa Pham, Administrator and Ruby Andrade, Business Manager		TIME VISIT/ INSPECTION COMPLETED:	05:09 PM

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Lisa Pham. The following (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan.

Operational Requirements:

A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for thirty (30) resident is approved.

Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2025. A surety bond is not applicable. Facility does not handle resident's money.

Facility changed name of facility to Savant of Alhambra without department approval. Citation issued.

Physical Plant/Environment Safety:

The building is located in a residential neighborhood. The building consists of three floors (ground floor, first floor and second floor). The ground floor/lobby consists of a front desk/reception area, business offices, three (3) activity rooms (tv, game room and activity room), health & wellness office, sales/marketing office, , laundry room, beauty salon, storage room, employee break room and garage. The first floor consists of resident rooms, dining room, kitchen, patio area and a storage room, and medication room. The second floor consists of resident rooms and a storage room. The facility has two (2) operable elevators.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALHAMBRA SENIOR VILLA	FACILITY NUMBER: 198603597
	VISIT DATE: 06/10/2024

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All resident rooms located on the first and second floors have a sliding door or a door leading to a balcony. Bedrooms were equipped with a bed, chair, nightstand, adequate lighting, and ample closet/storage space for each resident. Required linen/supplies which include, pillowcase, fitted sheet, blankets, bedspreads. Mattress pads were observed. The bathrooms are clean and operational with non-skid mats. The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. The supply of dishes/cups is adequate. During today's visit, LPA observed an appropriate food supply of two (2) days of perishables and seven (7) days of non-perishables.

The facility is equipped with a centralized sprinkler system. The facility has a central air and heating system in the common areas of the building and individual AC units inside resident bedrooms. The medications, First-aid kit and resident records are centrally stored and locked in the medication room. First aid kit is fully stocked with a manual. Staff records are centrally stored and locked at the front desk/reception area. Facility does not handle resident P&I monies. The facility smoke detectors are hard wired. Carbon monoxide detectors were observed throughout the facility. The fire extinguishers were fully charged and in compliance. There is a functioning telephone on the premises. The hot water temperature was tested throughout the facility and did not measure within Title 22 Regulations. Water temperature measure between 110.6 - 124.5 in random rooms that were inspected. Citation was issued. All toxins such as cleaning solutions and detergent soap are also locked in the storage room. The grounds of the facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the patio area. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises.

Staffing:

There appears to be always sufficient staffing in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.

Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 8 staff files with no issues observed. Administrator Lisa Pham certificate expired on 03/01/2024 renewal application was sent 01/2024 and certificate is pending.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALHAMBRA SENIOR VILLA	FACILITY NUMBER: 198603597
	VISIT DATE: 06/10/2024

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Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman near the resident mail room.

A total of four (4) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information. RCFE complaint poster and Personal rights were observed posted in the facility hallway.

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily.

The facility does have a Resident Council and meets monthly.

Food Service:

Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.

Incident Medical and Dental:

Eight (8) centrally stored resident medications were reviewed.

Medical and dental transportation is provided by family, transportation services, or staff.

Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Plan needs to be updated.

Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies.

Per California Code of Regulations, Title 22, deficiencies was cited. Technical Advisory provided.

Exit interview was conducted with Administrator Lisa Pham. A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/10/2024 04:55 PM - It Cannot Be Edited

Created By: Alberto Lopez On 06/10/2024 at 04:29 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALHAMBRA SENIOR VILLA	FACILITY NUMBER: 198603597
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above water in room 246 and 247 measured 121.8 and 125.5 degrees] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/11/2024
	Plan of Correction
1 2 3 4	Administrator had water adjusted and is now within range. *NO FURTHER ACTION REQUIRED*

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hicks

LICENSING EVALUATOR NAME:

Alberto Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 06/10/2024 04:55 PM - It Cannot Be Edited

Created By: Alberto Lopez On 06/10/2024 at 04:38 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALHAMBRA SENIOR VILLA	FACILITY NUMBER: 198603597
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87161(a)(2)

87161 Resubmission of Application (a) A new application shall be made whenever there is any change in conditions or limitations described on the current license, including, but not limited to: (2) Any change in the licensee This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. Facility changed the name of the facility from Alhambra Senior Villa to Savant of Alhambra without prior department approval. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/17/2024
	Plan of Correction
1 2 3 4	Facility will submit revised plan of operation as well as other documents required to change the name of the facility to LPA for approval by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hicks

LICENSING EVALUATOR NAME:

Alberto Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC809 (FAS) - (06/04)

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