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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603597
Report Date: 05/23/2023
Date Signed: 05/23/2023 10:40:23 AM

Document Has Been Signed on 05/23/2023 10:40 AM - 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 VILLAFACILITY NUMBER:
198603597
ADMINISTRATOR:MALEKSARKISSIANS, JINAFACILITY TYPE:
740
ADDRESS:1 E COMMONWEALTH AVETELEPHONE:
(626) 289-3871
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 176CENSUS: 64DATE:
05/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Executive Director / Jina MaleksarkissiansTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an announced follow up to the pre-licensing inspection conducted on 5/4/23. Upon arriving at the facility, LPA met with Executive Director / Jina Maleksarkissians, who assisted with the visit. 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 64 residents residing at the facility. The facility has an approved hospice care waiver for thirty (30) residents. Alhambra Senior Villa initially submitted Dementia Care as part of the plan of operation but on 5/16/23 the Central Applications Bureau (CAB) received an amended plan of operation removing Dementia Care from its plan of operation stating Alhambra Senior Villa will not accept or retain residents with a diagnosis of Dementia.

During the initial pre-licensing inspection conducted on 5/4/23, the following concerns were observed;

· Broken/loose tiles were observed in the patio area, near room 124.
    On 5/12/23, the Executive Director / Jina Maleksarkissians submitted pictures (via email) showing the broken/loose tiles in the patio area, near room 124 had been repaired/replaced. During today's inspection, LPA toured the patio area and observed the repair.
· 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
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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: 05/23/2023
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future residents with dementia. The facility does not have auditory devices or other staff alert features to monitor exits, if exiting presents a 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.
    On 5/16/23, LPA Katrdzhyan received an email from Bethany Hunter / Associate Governmental Program Analyst at the Centralized Applications Bureau stating that the Licensee has amended the plan of operation removing Dementia Care from the plan of operation and will not accept or retain resident with a diagnosis of Dementia.

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. No further action is needed at this time. 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: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
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