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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603597
Report Date: 04/03/2024
Date Signed: 04/03/2024 03:05:57 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
03/11/2024 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240311164325
FACILITY NAME:ALHAMBRA SENIOR VILLAFACILITY NUMBER:
198603597
ADMINISTRATOR:PHAM, LISAFACILITY TYPE:
740
ADDRESS:1 E COMMONWEALTH AVETELEPHONE:
(626) 289-3871
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY:176CENSUS: 91DATE:
04/03/2024
UNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Lisa Pham, Administrator TIME COMPLETED:
03:26 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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This report supersedes report dated 03/14/24 , the reason for the subsequent visit is to correct the citation issued on 3/14/24 and the finding will remain the same.**

On previous visit Licensing Program Manager made unannounced visit to investigate the above allegation. LPA met with Ruby Andrade, Business Office Manager and discussed the purpose of the visit. Administrator Lisa Pham arrived later during the visit.

Allegation: Facility is unsanitary. it is alleged that facility is very uncleaned that there may be a food shortage.
The investigation consisted of interviews with Twelve (12) staff S#1-S#12 and thirteen (13) residents (R#1- #13) residents, tour of all three floors, corridors, hallways, restrooms on all 3 floors, 13 random rooms, and reviewed staff and resident roosters. (Continued 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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 3
Control Number 28-AS-20240311164325
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: ALHAMBRA SENIOR VILLA
FACILITY NUMBER: 198603597
VISIT DATE: 04/03/2024
NARRATIVE
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The investigation revealed, based on observation of LPA and photos taken by LPA during the visit that facility is in need of replacing the carpet or deep cleaning the carpet in all the hallways on all 3 floors, and in rooms #140, #109, #152. Room 104 was observed very unclean during the visit by LPA.

Administrator stated that facility is in process of replacing the carpets with new floors. LPA interviewed 12 staff and 9 of 12 staff denied the allegation. 3 staff stated that facility is in need of new carpet in hallways and in some rooms. LPA interviewed 13 residents and 10 of 13 could not collaborate the allegations. 3 residents stated that the carpets at facility is very stained, dirty or both.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6.

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

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240311164325
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: ALHAMBRA SENIOR VILLA
FACILITY NUMBER: 198603597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by
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Administrator will deep clean or replace all carpets in the hallways and in rooms #140, #109, #152. Also, will provide room 140 an overall cleaning.
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Facility is in need of replacing the carpet or deep cleaning the carpet in all the hallways on all 3 floors, and in rooms #140, #109, #152. Room 104 was observed very unclean during the visit by LPA which pose/posses health and safety hazard to person 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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
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