Inspection Reports for
Savant of Alhambra
1 E COMMONWEALTH AVE, ALHAMBRA, CA, 91801
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
81% occupied
Based on a March 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 142
Capacity: 176
Deficiencies: 0
Date: Mar 10, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations regarding medication management and resident re-admission issues at the facility.
Complaint Details
The complaint included allegations that staff did not dispense medications as prescribed, did not properly manage medications, and did not allow a resident to be re-admitted after a psychiatric hold. The investigation was unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to substantiate the allegations related to improper medication dispensing, medication management, and denial of resident re-admission. Interviews with staff and residents and record reviews did not support the complaints.
Report Facts
Capacity: 176
Census: 142
Staff interviewed: 7
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Madeleine Sievert | Administrator | Facility administrator met during investigation |
| Lisa Pham | Regional Director of Operations | Assisted with the investigation visit |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 176
Deficiencies: 0
Date: Feb 20, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the licensee did not follow proper eviction protocols with a resident in care.
Complaint Details
The complaint alleged improper eviction protocols were followed. The investigation included interviews with seven staff and ten residents, and review of relevant documents. The allegation was unsubstantiated due to lack of evidence.
Findings
The investigation found insufficient evidence to substantiate the allegation. Staff and residents denied the eviction claim, and records showed the resident self-discharged and required a higher level of care. The allegation was determined to be unsubstantiated.
Report Facts
Facility Capacity: 176
Resident Census: 141
Staff interviewed: 7
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Madeleine Sievert | Administrator | Facility administrator who assisted with the visit |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 176
Deficiencies: 1
Date: Jan 17, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations including pest infestation, staff theft from residents, and failure to observe residents for changes in condition.
Complaint Details
The complaint investigation was substantiated for pest infestation in a resident's room. Allegations of staff theft and failure to observe residents were unsubstantiated due to lack of evidence.
Findings
The investigation substantiated the allegation that the facility failed to keep a resident's room free of pests, with evidence of dead cockroaches, spiders, and roach eggs found. Allegations of staff stealing from residents and failure to observe residents for changes in condition were unsubstantiated due to insufficient evidence.
Deficiencies (1)
CCR 87303(a) Maintenance and Operation: The facility was not clean and sanitary as evidenced by cockroach and insect infestation in resident room #141, posing a potential health and safety risk.
Report Facts
Capacity: 176
Census: 147
Staff interviewed: 6
Residents interviewed: 10
Pest control visits: 2
Roach eggs observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation and unannounced visits |
| Blanca Soliz | Resident Services Supervisor | Met with Licensing Program Analyst during investigation and exit interview |
| Madeleine Sievert | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 176
Deficiencies: 0
Date: Sep 23, 2025
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that staff did not ensure a resident's bandages were changed.
Complaint Details
The complaint alleged that staff did not change a resident's bandages, sending the resident with the same uncleaned bandages from two days prior. The investigation included interviews with staff, residents, and review of records. It was found that Home Health Agency is responsible for bandage changes, and the facility monitors after Home Health visits. The allegation was unsubstantiated due to lack of evidence.
Findings
The investigation found insufficient evidence to support the allegation. Staff denied the claim, residents could not corroborate it, and the facility stated that bandage care was the responsibility of Home Health services. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 176
Census: 140
Number of staff interviewed: 5
Number of residents interviewed: 10
Home health visits per week: 3
Dialysis visits per week: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Madeleine Sievert | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 176
Deficiencies: 2
Date: Jul 10, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff do not meet residents' basic needs due to insufficient staffing and that staff do not keep residents' rooms clean and sanitary.
Complaint Details
The complaint was substantiated based on observations, staff and resident interviews, and record reviews. The allegations involved insufficient staffing and failure to maintain clean and sanitary resident rooms.
Findings
The investigation substantiated the allegations, finding several resident rooms unclean with trash not emptied, restrooms not cleaned, linens not changed, and a resident found in a soiled undergarment. Staffing shortages were confirmed by staff interviews and observations.
Deficiencies (2)
CCR 87303(a): The facility was not clean, safe, sanitary, and in good repair. Several rooms were not cleaned, including trash not emptied, bathrooms not cleaned, and linens not changed, posing a health and safety issue.
CCR 87625(b)(3): The facility failed to ensure incontinent residents were kept clean and dry. Resident #1 was observed in a soiled diaper/undergarment, posing a health and safety issue.
Report Facts
Capacity: 176
Census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Madeleine Sievert | Administrator | Named in relation to findings and interviews during the complaint investigation |
| Nicol Wesley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
Inspection Report
Census: 143
Capacity: 176
Deficiencies: 2
Date: Jul 10, 2025
Visit Reason
The visit was a case management inspection triggered by a resident smoking cigarettes in a room where oxygen was being administered, posing a safety risk.
Findings
Two deficiencies were cited: the facility had both elevators broken simultaneously, posing a safety risk to non-ambulatory clients, and a resident was found smoking in a room with oxygen in use, which endangered the health and safety of clients.
Deficiencies (2)
CCR 87203 Fire Safety. The facility had two elevators broken at the same time, with one elevator broken since 05/31/25 and the other in disrepair for at least 3 hours during the visit. Non-ambulatory clients could not access their rooms, posing a health and safety risk.
CCR 87468.1(a)(2) Personal rights. A resident was found smoking in her room where oxygen was in use, sharing the room with another resident at risk, posing a health and safety risk to clients in care.
Report Facts
Capacity: 176
Census: 143
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Madeleine Sievert | Administrator | Spoke to resident about smoking issue and was present during the inspection |
| Nicol Wesley | Licensing Program Analyst | Conducted the case management visit and cited deficiencies |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 142
Capacity: 176
Deficiencies: 0
Date: Jun 23, 2025
Visit Reason
The inspection was an unannounced required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with licensing requirements.
Findings
The facility was found to be in compliance with all licensing requirements. Infection control, operational requirements, physical plant safety, staffing, personnel records, food service, disaster preparedness, and resident care were all satisfactory. No deficiencies were observed during the visit.
Report Facts
Days of perishables food supply: 2
Days of non-perishables food supply: 7
Number of resident medications reviewed: 10
Fire and disaster drills frequency: 1
Liability insurance per occurrence: 1000000
Liability insurance total annual aggregate: 3000000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Madeleine Sievert | Administrator | Met during inspection and participated in exit interview |
| Lisa Pham | Regional Director | Met during inspection and participated in exit interview |
| Alberto Lopez | Licensing Program Analyst | Conducted the inspection |
| Lisa Hicks | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 176
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations regarding medication mismanagement, unmet medical needs, grooming neglect, and food safety concerns at the facility.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, record reviews, and observations. Allegations included medication mismanagement, unmet medical needs, grooming neglect, and presence of bugs in food. The facility demonstrated compliance with medication administration, medical care access, grooming services, and food safety.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Medication administration was properly documented and given as prescribed, medical needs were generally met with in-house doctors and transportation provided, grooming services including podiatry were available, and the kitchen and dining areas were clean with no evidence of bugs in food.
Report Facts
Capacity: 176
Census: 140
Residents interviewed: 14
Staff interviewed: 5
Medication logs reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Madeline Sievert | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Nune Margaryan | Licensing Program Analyst | Conducted complaint investigation and authored report |
Inspection Report
Complaint Investigation
Census: 152
Capacity: 176
Deficiencies: 1
Date: May 16, 2025
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that staff do not meet residents' basic needs due to insufficient staffing and that residents' rooms are not kept clean and sanitary.
Complaint Details
The complaint investigation was substantiated based on observations and interviews. Allegations included insufficient staffing and failure to keep residents' rooms clean and sanitary. Evidence met the preponderance of evidence standard.
Findings
The investigation substantiated the allegations, finding that several rooms were not cleaned, including unemptied trash, unclean restrooms, unchanged linens, and a resident in soiled undergarments. Staff interviews confirmed staffing shortages and residents reported rooms were not cleaned as scheduled.
Deficiencies (1)
CCR 87303(a): The facility failed to maintain clean, safe, and sanitary conditions. Several rooms were found unclean, including trash not emptied, bathrooms not cleaned, and linens not changed.
Report Facts
Capacity: 176
Census: 152
Plan of Correction Due Date: May 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Madeleine Sievert | Administrator | Met with Licensing Program Analyst during investigation and provided staffing information |
| Nicol Wesley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
Inspection Report
Census: 152
Capacity: 176
Deficiencies: 3
Date: May 16, 2025
Visit Reason
The visit was a case management inspection triggered by a resident smoking cigarettes in a room where oxygen was being administered, posing a safety risk.
Findings
Two Type A deficiencies were cited: the facility had both elevators broken simultaneously, posing a health and safety risk to non-ambulatory residents, and a resident was found smoking in a room with oxygen in use, risking personal safety.
Deficiencies (3)
CCR 87203 Fire Safety. The facility had two elevators broken at the same time, preventing non-ambulatory clients from accessing their rooms, posing a health and safety risk.
HSC 87468.1 Personal rights. A resident was smoking in her room where oxygen was in use, endangering herself and another resident sharing the room.
CCR 87303(a) The facility was not maintained in good repair as both elevators were broken simultaneously, limiting resident mobility and access.
Report Facts
Census: 152
Total Capacity: 176
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Madeleine Sievert | Administrator | Spoke to resident about smoking issue and was present during inspection |
| Nicol Wesley | Licensing Program Analyst | Conducted the case management visit and cited deficiencies |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 143
Capacity: 176
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not meet a resident's hygiene needs.
Complaint Details
The complaint alleged that staff failed to provide proper hygiene services to resident R1, who was observed with dead skin and mold fuzz between toes. Interviews and record reviews contradicted the allegation, and R1 was hospitalized during part of the investigation. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff and residents, review of records, and a facility tour. The allegation was found to be unsubstantiated due to insufficient evidence, with staff and most residents denying the claim and documentation showing resident refusals of hygiene services.
Report Facts
Capacity: 176
Census: 143
Staff interviewed: 6
Residents interviewed: 11
Shower refusal forms reviewed: 9
Hospitalization dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Madeleine Sievert | Administrator | Facility administrator involved in the investigation and exit interview |
| Lisa Pham | Regional Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 176
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that facility elevators were in disrepair causing delays in emergency medical response to residents.
Complaint Details
The complaint alleged that facility elevators were in disrepair causing delays in emergency medical response. The allegation was unsubstantiated after investigation, with no preponderance of evidence to prove violations occurred.
Findings
The investigation found that although the elevators had been out of service previously, they were repaired promptly and were in working condition at the time of the visit. Interviews with staff and residents confirmed timely repairs and no issues with emergency evacuation. The allegations were unsubstantiated due to insufficient evidence.
Report Facts
Immediate civil penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christian Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and inspection. |
| Madeleine Sievert | Administrator | Facility administrator interviewed during investigation. |
| Tony Vasallo | Licensing Program Manager | Named in report header and signature section. |
Inspection Report
Census: 134
Capacity: 176
Deficiencies: 3
Date: Apr 3, 2025
Visit Reason
The visit was a case management inspection triggered by a resident smoking cigarettes in a room where oxygen was being administered, posing a safety risk.
Findings
The inspection found that a resident was smoking in a room with oxygen in use, which is a safety hazard. Additionally, both elevators in the facility were broken at the same time, restricting mobility for non-ambulatory residents.
Deficiencies (3)
CCR 87203 Fire Safety: The facility had two elevators broken simultaneously, posing a health and safety risk to non-ambulatory clients who could not access their rooms or leave them.
CCR 8746.1(a)(2) Personal Rights: A resident was found smoking in her room where oxygen was in use, endangering herself and another resident sharing the room.
CCR 87303(a) Facility Maintenance: The facility was not clean, safe, sanitary, and in good repair as both elevators were broken at the same time, impacting resident safety and mobility.
Report Facts
Census: 134
Total Capacity: 176
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Madeleine Sievert | Administrator | Spoke to resident about smoking issue and was present during inspection |
| Nicol Wesley | Licensing Program Analyst | Conducted the case management visit and cited deficiencies |
| Lisa Hicks | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 176
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2025-02-21 regarding inadequate food service, toileting supplies, and housekeeping services at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate food service, toileting supplies, and housekeeping services. Interviews with staff and residents and facility observations did not support these allegations.
Findings
The investigation found insufficient evidence to substantiate the allegations of inadequate food service, toileting supplies, and housekeeping services. Interviews with staff and residents, observations, and facility tours did not corroborate the complaints.
Report Facts
Capacity: 176
Census: 140
Staff interviewed: 6
Residents interviewed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Madeleine Sievert | Administrator | Facility administrator met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 140
Capacity: 176
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2025-01-30 regarding medication mismanagement, response to call buttons, infection control, elevator disrepair, and other resident care concerns.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included medication mismanagement, delayed response to call buttons, failure to follow infection control, elevator disrepair, untimely repairs, and unmet resident needs. Interviews and inspections did not corroborate these claims.
Findings
The investigation included interviews with staff and residents, medication and record reviews, and facility inspections. All allegations were found to be unsubstantiated due to insufficient evidence to prove violations occurred.
Report Facts
Capacity: 176
Census: 140
Staff interviewed: 8
Residents interviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
| Madeline Sievert | Administrator | Facility representative met during inspection and exit interview |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 176
Deficiencies: 0
Date: Jan 3, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of staff mismanaging resident medication and leaving a resident in a soiled diaper for an extended time.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff mismanagement of medication and leaving a resident in a soiled diaper for over 30 minutes multiple times. Interviews and record reviews did not provide sufficient evidence to prove the allegations.
Findings
The investigation found insufficient evidence to substantiate the allegations. Medication records and interviews indicated no missed medications, and while some residents reported delays in diaper changes, staff denied leaving residents in soiled diapers for extended periods.
Report Facts
Capacity: 176
Census: 118
Residents interviewed: 10
Staff interviewed: 4
Resident #1 stay duration: 6
Residents reporting timely medication: 7
Residents reporting long wait for diaper change: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Madeleine Sievert | Interim Administrator | Interviewed during the investigation and exit interview |
| Lisa Pham | Administrator | Named as facility administrator |
| Tony Vasallo | Licensing Program Manager | Named in report header and signature |
Inspection Report
Census: 128
Capacity: 176
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
Licensing Program Analyst Alberto Lopez made an unannounced visit to inspect the dementia care section of the facility to approve the facility's request to advertise for dementia care.
Findings
The facility does not have a specific area for dementia care and will only accept early onset dementia residents. The exit door leading to the garage and front exit lacked an alert system, which the facility plans to address by installing audio systems.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Pham | Administrator | Reported to LPA that the facility does not have a specific area for dementia care. |
| Madeleine Sievert | Acting Administrator | Met with LPA during the inspection and discussed the purpose of the visit. |
| Alberto Lopez | Licensing Program Analyst | Conducted the unannounced visit and inspection. |
Inspection Report
Complaint Investigation
Census: 132
Capacity: 176
Deficiencies: 2
Date: Oct 8, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2024-09-04 regarding medication errors and bathing service issues at the facility.
Complaint Details
The complaint investigation was substantiated for medication errors including incorrect medication dispensed and untimely medication administration. The allegations about improper medication record keeping and failure to provide bathing service were unsubstantiated.
Findings
The investigation substantiated two allegations: staff dispensed incorrect medications to a resident and medications were not administered in a timely manner. Two other allegations regarding medication record maintenance and bathing service were unsubstantiated.
Deficiencies (2)
CCR 87465(c)(2) was not met as a resident was given medication belonging to another resident on July 26, 2024, posing an immediate health and safety risk.
CCR 87465(a)(5) was not met as a resident did not receive medication on time on at least one night due to staff forgetting, posing an immediate health and safety risk.
Report Facts
Capacity: 176
Census: 132
Staff interviewed: 8
Residents interviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Pham | Administrator | Met with Licensing Program Analyst during investigation and named in report |
| Alberto Lopez | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Ruby Andrade | Business Manager | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 176
Deficiencies: 0
Date: Sep 3, 2024
Visit Reason
The visit was an unannounced complaint investigation to examine allegations that facility staff were not assisting a resident with attending dialysis appointments as required.
Complaint Details
The complaint alleged that facility staff were not assisting a resident with attending dialysis appointments. The allegation was unsubstantiated after interviews with staff, residents, and the resident, as well as review of relevant medical and incident reports.
Findings
The investigation found that the resident refused dialysis appointments and did not blame the facility. Staff and residents interviewed denied the allegation, and documentation showed the facility reported the resident's refusal to attend dialysis. There was no evidence to substantiate the allegation.
Report Facts
Capacity: 176
Census: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Pham | Administrator | Facility administrator who assisted with the visit and received the report |
| Alberto Lopez | Licensing Program Analyst | Investigator who conducted the complaint investigation |
Inspection Report
Annual Inspection
Census: 83
Capacity: 176
Deficiencies: 2
Date: Jun 10, 2024
Visit Reason
Licensing Program Analyst Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with regulatory requirements.
Findings
The facility demonstrated compliance with infection control, operational requirements, physical plant safety, staffing, personnel records, residents' rights, planned activities, food service, incident medical and dental, and disaster preparedness. However, citations were issued for water temperature exceeding regulatory limits and for changing the facility name without department approval.
Deficiencies (2)
CCR 87303(e)(2) Water supplies and plumbing fixtures did not maintain hot water temperature within the required range; water in rooms 246 and 247 measured 121.8 and 125.5 degrees Fahrenheit, posing an immediate health and safety risk.
CCR 87161(a)(2) Facility changed the name from Alhambra Senior Villa to Savant of Alhambra without prior department approval, posing a potential health, safety, or personal rights risk.
Report Facts
Resident census: 83
Total licensed capacity: 176
Perishable food supply: 2
Non-perishable food supply: 7
Staff files reviewed: 8
Resident medication files reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Pham | Administrator | Named in relation to inspection and citation for facility name change and certificate renewal status |
| Alberto Lopez | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lisa Hicks | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 176
Deficiencies: 1
Date: Apr 3, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that the facility is in disrepair and unsanitary, with concerns about cleanliness and a possible food shortage.
Complaint Details
The complaint was substantiated. The investigation included interviews with 12 staff and 13 residents, observations, and photos. Some staff and residents corroborated the allegations of unclean carpets and facility disrepair.
Findings
The investigation found that the facility is in need of replacing or deep cleaning carpets in all hallways on three floors and in specific rooms (#140, #109, #152). Room 104 was observed to be very unclean, posing a health and safety hazard. The allegation was substantiated based on observations, photos, and interviews with staff and residents.
Deficiencies (1)
CCR 87303(a): The facility is not clean, safe, sanitary, and in good repair as evidenced by the need to replace or deep clean carpets in hallways and rooms #140, #109, and #152, and the very unclean condition of room 104 posing a health and safety hazard.
Report Facts
Capacity: 176
Census: 91
Staff interviewed: 12
Residents interviewed: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Pham | Administrator | Named in relation to facility condition and exit interview |
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 176
Deficiencies: 1
Date: Mar 14, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that the facility is unsanitary and may have a food shortage.
Complaint Details
The complaint alleging the facility is unsanitary was substantiated based on observations, photos, and interviews with 12 staff and 13 residents. Some staff and residents confirmed the need for new or cleaned carpets and noted stained or dirty carpets.
Findings
The investigation found that the facility needs to replace or deep clean carpets in all hallways on three floors and in specific rooms (#140, #109, #152). Room 104 was observed to be very unclean, posing a health and safety hazard. The allegation was substantiated based on observations, photos, and interviews with staff and residents.
Deficiencies (1)
CCR 87003(a): The facility shall be clean, safe, sanitary and in good repair at all times. The facility is in need of replacing or deep cleaning carpets in all hallways on three floors and rooms #140, #109, #152. Room 104 was observed very unclean, posing a health and safety hazard.
Report Facts
Census: 94
Total Capacity: 176
Staff interviewed: 12
Residents interviewed: 13
Plan of Correction Due Date: Apr 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Pham | Administrator | Named in relation to facility condition and exit interview |
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 176
Deficiencies: 0
Date: Mar 12, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were not timely showering, changing, assisting with medications, and providing basic hygiene products to residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included untimely showering, changing, medication assistance, and provision of hygiene products. Interviews with staff and residents, as well as review of schedules and hygiene supplies, did not support the allegations.
Findings
The investigation found that staff and residents did not corroborate the allegations. Staff interviews and observations indicated that residents receive timely assistance with showering, changing, medications, and hygiene products. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 176
Census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Pham | Administrator | Assisted with the complaint investigation visit |
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation |
| Madeleine Sievert | Wellness Coordinator | Assisted with the complaint investigation visit |
Inspection Report
Original Licensing
Census: 64
Capacity: 176
Deficiencies: 5
Date: May 23, 2023
Visit Reason
The visit was an announced follow-up to a pre-licensing inspection for a Residential Care Facility for the Elderly, processing a change of ownership and application for operation with a capacity of 176 residents.
Findings
The inspection found that broken/loose tiles near room 124 were repaired. However, the facility was not suitable for residents with dementia due to unsafe sliding doors, unsecured medications and cleaning supplies in resident rooms, lack of auditory or staff alert devices, and unenclosed outdoor recreation space. The plan of operation was amended to remove Dementia Care and the facility will not accept or retain residents with dementia.
Deficiencies (5)
Broken/loose tiles were observed in the patio area near room 124 but were repaired prior to this inspection.
Resident rooms on the first and second floors have sliding doors or doors leading to balconies, making them unsafe for residents with dementia.
Medications, cleaning supplies, and scissors were found unsecured in rooms 149, 145, 232, and 203, posing safety risks for residents with dementia.
The facility lacks auditory devices or staff alert features to monitor exits, which is a hazard for residents with dementia.
The outdoor recreation area is not enclosed by a fence with self-closing latches and gates, compromising safety for residents with dementia.
Report Facts
Capacity: 176
Census: 64
Fire clearance capacity: 166
Fire clearance capacity: 10
Hospice care waiver capacity: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jina Maleksarkissians | Executive Director | Met with Licensing Program Analyst during inspection and submitted repair photos |
| Joe Katrdzhyan | Licensing Program Analyst | Conducted the inspection and authored the report |
| Bethany Hunter | Associate Governmental Program Analyst | Communicated amendment to plan of operation removing Dementia Care |
Inspection Report
Original Licensing
Census: 62
Capacity: 176
Deficiencies: 5
Date: May 4, 2023
Visit Reason
The inspection was conducted as a pre-licensing visit for a Residential Care Facility for the Elderly with a capacity of 176 residents, including dementia care and hospice care programs, as part of a change of ownership application.
Findings
The facility was toured and inspected for compliance with Title 22 regulations, including safety, health, and physical plant conditions. Several concerns were identified related to safety hazards for future residents with dementia, including unsafe sliding doors leading to balconies, unsecured medications and cleaning supplies in resident rooms, lack of auditory exit monitoring devices, broken tiles in the patio area, and unenclosed outdoor recreation space.
Deficiencies (5)
Broken and loose tiles were observed in the patio area near room 124, posing a safety hazard.
All resident rooms on the first and second floors have sliding doors or doors leading to balconies, making them unsafe for future residents with dementia.
Medications, cleaning supplies, and scissors were found unsecured in rooms 149, 145, 232, and 203, creating safety risks for residents with dementia.
The facility lacks auditory devices or staff alert features to monitor exits, which is a hazard for residents with dementia.
The outdoor facility space used for resident recreation is not enclosed by a fence with self-closing latches and gates, compromising safety for residents with dementia.
Report Facts
Facility capacity: 176
Current census: 62
Fire clearance capacity: 166
Fire clearance capacity: 10
Hospice care waiver capacity: 30
Food supply: 2
Food supply: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jina Maleksarkissians | Executive Director | Met during pre-licensing inspection and named in report |
| Moises Bercovich | Licensee Representative | Met during pre-licensing inspection and named in report |
| Joe Katrdzhyan | Licensing Program Analyst | Conducted the pre-licensing inspection |
Inspection Report
Census: 60
Capacity: 176
Deficiencies: 0
Date: Apr 5, 2023
Visit Reason
The visit was conducted as an office evaluation related to a change of ownership application for the facility.
Findings
The applicant/administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.
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