198603597-5-4-2023-28-AS-JKAN-CRHUC6-20230504152725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603597
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:27:51 PM

Document Has Been Signed on 05/04/2023 03:27 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ALHAMBRA SENIOR VILLA		FACILITY NUMBER:	198603597
ADMINISTRATOR:	MALEKSARKISSIANS, JINA		FACILITY TYPE:	740
ADDRESS:	1 E COMMONWEALTH AVE		TELEPHONE:	(626) 289-3871
CITY:	ALHAMBRA	STATE: CA	ZIP CODE:	91801
CAPACITY: 176		CENSUS: 62	DATE:	05/04/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Executive Director / Jina Maleksarkissians Licensee Representative / Moises “Mochi” Bercovich		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an announced pre-licensing visit. LPA met with Licensee Representative / Moises “Mochi” Bercovich and Executive Director / Jina Maleksarkissians for the purpose of conducting a pre-licensing inspection. Licensee / Alhambra Senior Villa LLC has submitted an application to operate a Residential Care Facility for the Elderly for a capacity of one hundred and seventy six (176) residents, ages 60 and over. The facility has an approved fire clearance for one hundred and sixty six (166) non-ambulatory residents and ten (10) bedridden residents only. The bedridden residents may only reside in rooms, 122, 123, 124, 125, 126, 152, 153, 154, 155 and 156. The new application is being processed as a change of ownership. There are currently 62 residents residing at the facility. Alhambra Senior Villa has a Dementia Care Program and will be accepting and caring for residents with dementia, upon licensure. The facility has an approved hospice care waiver for thirty (30) residents. LPA utilized the Pre-licensing inspection tool and the pre-licensing checklist for a Residential Care Facility for the Elderly, during this visit. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. 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, medication room, 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. The second floor consists of resident rooms and a storage room. The facility has two (2) operable elevators. All resident rooms located on the first and second floors have a sliding door or a door leading to a balcony. LPA observed a fully equipped living room and a dining room with sufficient dining capacity. Resident bedrooms were inspected for linens and personal accommodations for safety, privacy, and comfort. Resident

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALHAMBRA SENIOR VILLA	FACILITY NUMBER: 198603597
	VISIT DATE: 05/04/2023

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bedrooms were equipped with a bed, chair, night stand, 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 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 measured within Title 22 Regulations. 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.

LPA observed the Emergency Disaster Plan, Personal Rights and Facility Sketch posted inside the facility as mandated by Title 22 Regulations. Component III was conducted during this visit.

The following concerns were observed during today's visit;

· Broken/loose tiles were observed in the patio area, near room 124.
· All resident rooms located on the first and second floors have a sliding door or a door leading to a balcony, making it unsafe for future residents with dementia.
· Medications, cleaning supplies (such as Windex, Laundry Detergent and Bleach) and scissors were observed in rooms 149, 145, 232 and 203, making it unsafe for future residents with dementia.
· The facility does not have auditory devices or other staff alert features to monitor exits, if exiting presents a

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALHAMBRA SENIOR VILLA	FACILITY NUMBER: 198603597
	VISIT DATE: 05/04/2023

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hazard to residents with a diagnosis of dementia.
· The outdoor facility space used for resident recreation and leisure is not enclosed by a fence with self-closing latches and gates, to protect the safety of future residents with dementia.

The Licensee / Executive Director understand the following items related to Dementia;

· Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.
· The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.
· Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely.

Prior to licensure, the Licensee shall ensure that the facility is in compliance with California Code of Regulations Title 22, Section 87705, Care of Persons with Dementia.

LPA to return on another day to observe corrections. An exit interview was conducted and a copy of this report has been furnished to the Applicants. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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