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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603790
Report Date: 03/23/2026
Date Signed: 03/30/2026 04:02:27 PM

Document Has Been Signed on 03/30/2026 04:02 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALHAMBRA VILLAFACILITY NUMBER:
198603790
ADMINISTRATOR/
DIRECTOR:		COREAS, OKKYUNGFACILITY TYPE:
740
ADDRESS:528 HOWARD STREETTELEPHONE:
(213) 820-3244
CITY:ALHAMBRASTATE: CAZIP CODE:
91801
CAPACITY: 14CENSUS: 8DATE:
03/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:02 PM
MET WITH:Ilki Baek, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:29 PM
NARRATIVE
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This report supersedes previous report, It is being changed to correct type of visit and nothing else has changed.
Licensing Program Analyst (LPA) Alberto Lopez conducted an announced annual inspection visit and met with Ilki Baek, Caregiver, and discussed the purpose of the visit. . The facility has an approved fire clearance for 11 non-ambulatory residents, and three (3) bedridden residents. The facility is a single-story home: 9 bedrooms, and 7 bathrooms, dining/ living room, backyard with detached garage used for laundry and storage, located in Alhambra, CA

Infection Control:

The facility staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, an Infection Control Plan. Bathrooms have hand washing signs, soap and paper towels. Facility Administrator is adhering to infection control requirements.

Operational Requirements: Facility has proper fire clearance and shaded area for activities.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator, and S1-S3. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained in Abuse Reporting. Administrator Certificate expires on 09/08/2026. (Continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/23/2026 05:24 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/23/2026 at 05:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALHAMBRA VILLA
FACILITY NUMBER: 198603790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA observed several cans of food had expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee will dispose of all expired food items and send proof to LPA by POC date.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation AND record review, the licensee did not comply with the section cited above several resident's medications did not have labels (details provided to Licensee) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee will make sure all PRN, medications and over the counter have labels and send proof to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2026


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/23/2026 05:24 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/23/2026 at 05:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALHAMBRA VILLA
FACILITY NUMBER: 198603790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(1)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Several residents did not have labels on their medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee will apply labels to all medications and send proof to LPA

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/23/2026 05:24 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/23/2026 at 05:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALHAMBRA VILLA
FACILITY NUMBER: 198603790

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. One resident's pre admission Appraisal was not completed and blank which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee will complete the Pre admission Appraisal for resident's (details provided to Licensee) and send proof to LPA
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 VILLA
FACILITY NUMBER: 198603790
VISIT DATE: 03/23/2026
NARRATIVE
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(continued from 809)

Resident Rights-Information: resident personal rights and House Rules are posted. Per Facility Administrator, facility provides wi-fi services for facility residents. .

(Continued on 809C)

Resident Records-Incident Reports: LPA reviewed resident files for C1 through C4. Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Appraisal Needs and Services Plan, Functional Capabilities Assessment, Mental Health Intake Assessment, Client Cash Resources. Special Incident Reports, Client Personal Property and Clients Personal Rights. One resident’s Pre-Admission Appraisal is blank. Details provided to Licensee.

Food Service: The facility has sufficient food supplies of 2-day perishable and 7-day supply of non-perishable items. The food is properly stored in the refrigerator, which is clean and well maintained. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other bugs/ insects. Plates, cups and utensils are kept clean and stored properly. Several cans of food are expired and were immediately discarded.

Health Related Services: The medications are centrally stored and in their original containers. LPA reviewed medication for R1-R4. The facility uses the Medication Administration Record (MAR) log to document medications given. All medications are not administered as prescribed by the Physician. Some medications do not have orders, and some do not have labels. Details provided to Licensee for corrections.

Incidental Medical Services: Per Facility Administrator, there are no residents at this home with incidental medical services or restricted health condition.

Emergency Intervention: Not Applicable.

LPA will return to complete 2 other domains on another day. Deficiencies noted. Technical violation issued. Exit interview and a copy of this report, appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
LIC809 (FAS) - (06/04)
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