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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197802426
Report Date: 02/23/2021
Date Signed: 02/24/2021 05:02:18 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
09/08/2020 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200908104951
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: 69DATE:
02/23/2021
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Tracey Holder, Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility failed to follow reporting requirements.
Facility failed to issue refund after resident's death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit to deliver the findings for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Tracey Holder, Executive Director.

During the initial visit on 9/15/20, LPA Chan conducted telephone interviews with the Executive Director and 2 Staff. LPA requested copies of the Staff and Resident rosters containing their contact information. LPA also requested for the following documents for 5 residents: Identification and Emergency Information sheet, Admission Agreement, Personal Property and Valuables form (LIC621) to be emailed to the LPA. LPA Chan held additional phone interviews with 2 staff members another day.

(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: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
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 5
Control Number 28-AS-20200908104951
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: 02/23/2021
NARRATIVE
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Regarding allegation - Facility failed to follow reporting requirements. Based on information gathered from the interviews, most death and incidents are verbally reported to the families and not provided with a written report. Per Administrator, written reports for death and serious injuries are not provided to families unless requested. According to staff interviewed, they have made phone calls to the families but do not know if a written report is provided to them. The Administrator revealed that a family member had recently requested for a detailed summary regarding the death of a resident and the report was provided on 8/7/2020. Based on the information received, the Administrator did not provide the person responsible for the resident with the written report within seven days of the death as per regulations.


Regarding allegation - Facility failed to issue refund after resident's death. Per Administrator, when a resident moves out or is deceased, the refund is issued to the family within 15 days and the amount is determined by the corporate office. Refunds are not done at the facility. According to the Business Office Coordinator, after resident's belongings are moved out of the facility, she would input the date into their system. The corporate office receives the information, calculates the remaining amount to be refunded, and then issues the refund check to the family. On 2/11/21, Administrator obtained verification that a refund check for Client #3, who passed away on 6/9/2020 and personal belongings were moved out on 6/13/2020, was created on 7/10/2020. It was confirmed by the family member that the refund check was not obtained within 15 days after the personal property was removed.

Based on LPA interviews and record review, 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 LIC9099D.

An exit interview was conducted. A copy of this report and the Plan of Correction were emailed to Tracey Holder for a signature. The Appeal Rights were also provided.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20200908104951
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: 02/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/02/2021
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...specified in (A) through (D) below...
This requirement is not met as evidenced by:
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The Administrator shall read the 87211 Reporting Requirements regulation and submit a statement acknowledging she has read and understand the reporting requirements by POC due date of 3/2/2021.
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Based on interviews, the licensee did not ensure that the person responsible for the deceased resident is provided with a written report within seven days, which poses a potential personal rights risk to the residents.
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Type B
03/02/2021
Section Cited
HSC
1569.652(c)
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§1569.652 Termination of admission agreement upon death of resident; removal of resident ’s property; refund of fees paid; notice of contract termination and refunds (c)A refund of any fees paid in advance... shall be issued to the individual...within 15 days after the personal property is removed.
This requirement is not met as evidenced by:
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The Administrator shall read the Health and Safety code under 1569.652 to ensure that residents receive refunds according to the regulations. The Administrator will submit a statement indicating that this regulation has been read and understood by POC due date of 3/2/2021.
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Based on interviews, a refund was not issued within 15 days after resident's personal belongings were removed, which poses a potential personal rights risk to the residents.
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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: 02/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/08/2020 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200908104951

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: 69DATE:
02/23/2021
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Tracey Holder, Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit to deliver the findings for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Tracey Holder, Executive Director.

During the initial visit on 9/15/20, LPA Chan conducted telephone interviews with the Executive Director and 2 Staff. LPA requested copies of the Staff and Resident rosters containing their contact information. LPA also requested for the following documents for 5 residents: Identification and Emergency Information sheet, Admission Agreement, Personal Property and Valuables form (LIC621) to be emailed to the LPA. LPA Chan held additional phone interviews with 2 staff members another day.

(Continue on LIC9099C)
Unsubstantiated
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: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20200908104951
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: 02/23/2021
NARRATIVE
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Regarding allegation – Facility failed to safeguard resident’s personal belongings. It is alleged that resident’s personal belongings such as a Mickey Mouse watch and a set of pearl earrings were missing at the facility. Based on interviews with the Administrator and staff, no one has ever seen the resident with a Mickey Mouse watch nor a set of pearl earrings. In addition, Administrator stated that resident’s room was locked to secure any belongings after the resident passed away. LPA reviewed the LIC621 Resident Personal Property and Valuables form and did not observed any items recorded on this form. Therefore, there was insufficient evidence to corroborate this allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.



An exit interview was conducted. A copy of this report was emailed to the Executive Director for a signature.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5