SAVANT OF ALHAMBRA

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observations, interviews and documents reviewed, the resident’s room continues to have issues with cockroaches and other insects which poses a potential health and safety risk to residents in care. LPA observed dead spiders in freezer door, dead roach on the floor and 4 roach eggs in the room #141

Official plan of correction

Facility will address the cockroach and insect issue and send progress report that shows room 141 has been treated by pest control to LPA. Facility will remove all dead pest, roach eggs and insects from room and send proof to LPA by POC date of 01/27/2026

Deadline recorded: Jan 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This item was not met as evidence by: the facility had two elevators broken at the same time. the 1st elevator was broken since last monday 05/31/25, and the 2nd was in disrepair for at least 3 hours while LPA Wesley was in the building, the facility had it fixed, and it broke again. The Non Ambulatory clients could not get to their room which posed a health and safety issue to the cleints in care.

Official plan of correction

The facility shall ensure all elevators are working properly at all times. Please provide the service repair sheet for the elevator for today encounter to Attn Nicol Wesley 323 980 4912 by POC date 07/11/25

Deadline recorded: Jul 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This item was not met as evidence by: the facility had two elevators broken at broken since last monday 05/31/25, and the 2nd was in disrepair for at least 3 hours while LPA Wesley was in the building, the had it fixed, and it broke again. The Non Ambulatory clients could not get to their room which posed a health and safety risk to clients in care.

Official plan of correction

The facility shall ensure all elevators are working properly at all times. Please provide the service repair sheet for the elevator for today encounter to Attn Nicol Wesley 323 980 4912 by POC date 07/11/25

Deadline recorded: Jul 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal rights Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This evidence was not met as required: LPA Wesley and the Administrator found resident #1 was smoking in her room where oxygen was in use. She also shares a room with the another resident who was at risk. Which posed a health and safety risk to the clients in care.

Official plan of correction

The Administrator advised that she spoke to the resident previously and documented her conversation. The administrator shall come up with a plan and give a copy to the LPA to ensure the resident is in compliance by 07/11/25, to Atth: Nicol Wesley 323 980 4912.

Deadline recorded: Jul 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This evidence was not met as required LPA and the Administrator observed several rooms that were not cleaned by staff, which includes emptying the trash, cleaing the bathrooms, and changing the linen. which poses a health and safety issue for all clients in care.

Official plan of correction

The administrator shall ensure all the residents rooms are clean. Create an inservice training " Maintenace and Operations " for all staff and go over what needs to be cleaned, incase they don't understand their dutied. The facility will hire more staff if necessary. Submit the in service training sign in sheet to LPA Wesley 323 980 4912 by the POC date 07/11/25.

Deadline recorded: Jul 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

Managed Incontinence, In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. LPA Wesley and Administrator Sievert observed Resident #1 to be in a soiled diaper/undergarment, when asked, he mentioned last night sometime, the Administrator said she dont remember this conversation. Which poses a health and safety issue to clients in care.

Official plan of correction

The facility Administator will ensure all residents diaper/undergarment will be changed and monitored every two hours or as needed. The Administrator will have a log of all the residents who are incontinent and have the staff initial when they have been checked. Send the incontinence log to LPA Wesley by POC date 07/17/25.

Deadline recorded: Jul 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This item was not met as evidence by: the facility had two elevators broken at the same time. the 1st elevator was broken since last monday 05/31/25, and the 2nd was in disrepair for at least 3 hours while LPA Wesley was in the building, the had it fixed, and it broke again. The Non Ambulatory clients could not get to their room which posed a health and safety risk to clients in care.

Official plan of correction

The facility shall ensure all elevators are working properly at all times. Please provide the service repair sheet for the elevator for today encounter to Attn Nicol Wesley 323 980 4912 by POC date 04/04/25

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1

Regulation authority

HSC

What the official deficiency says

Personal rights Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This evidence was not met as required: LPA Wesley and the Administrator found resident #1 was smoking in her room where oxygen was in use. She also shares a room with the another resident who was at risk.

Official plan of correction

The Administrator advised that she spoke to the resident and documented her conversation. The administrator shall come up with a plan to ensure the resident is in compliance. Give a copy of the plan to Atth: Nicol Wesley 323 980 4912.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The requirement was not met as evidence by LPA Wesley witnessed the facility elevators(two) were broke at the same time and the non ambulatory clients couldn't go to their rooms or leave their rooms to visit friends, eat lunch etc.

Official plan of correction

The facility shall make sure the elevators are working at all times, and have them serviced. please send elevator repair sheet to LPA Wesley 323 980 4912 By POC date 04/04/25.

Deadline recorded: Apr 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This evidence was not met as required LPA and the Administrator observed several rooms that were not cleaned by staff, which includes emptying the trash, cleaing the bathrooms, and changing the linen.

Official plan of correction

The administrator shall ensure all the residents rooms are clean. Create an inservice training " Maintenace and Operations " for all staff and go what needs to be cleaned. HIre more staff if necessary. Submit the in service training sign in sheet to LPA Wesley 323 980 4912 by the POC date 05/30/25.

Deadline recorded: May 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This item was not met as evidence by: the facility had two elevators broken at the same time. the 1st elevator was broken since last monday 05/31/25, and the 2nd was in disrepair for at least 3 hours while LPA Wesley was in the building, the had it fixed, and it broke again. The Non Ambulatory clients could not get to their room which posed a health and safety risk to clients in care.

Official plan of correction

The facility shall ensure all elevators are working properly at all times. Please provide the service repair sheet for the elevator for today encounter to Attn Nicol Wesley 323 980 4912 by POC date 04/04/25

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

8746.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal rights Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This evidence was not met as required: LPA Wesley and the Administrator found resident #1 was smoking in her room where oxygen was in use. She also shares a room with the another resident who was at risk.

Official plan of correction

The Administrator advised that she spoke to the resident and documented her conversation. The administrator shall come up with a plan to ensure the resident is in compliance. Give a copy of the plan to Atth: Nicol Wesley 323 980 4912.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The requirement was not met as evidence by LPA Wesley witnessed the facility elevators(two) were broke at the same time and the non ambulatory clients couldn't go to their rooms or leave their rooms to visit friends, eat lunch etc.

Official plan of correction

The facility shall make sure the elevators are working at all times, and have them serviced. please send elevator repair sheet to LPA Wesley 323 980 4912 By POC date 04/04/25.

Deadline recorded: Apr 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) (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: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: On July 26th 2024, R1 was given medication that belonged to another resident by mistake which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Facility will complete an incident report documenting the medication error. The report will include if the primary physician has been notified of the error. Administrator shall ensure all med-tech staff received additional training. Sign-in sheet and training material will be emailed to LPA by the POC due date. Administrator will include in writing the steps taken to avoid future medication errors by POC due date.

Deadline recorded: Oct 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(5) The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Resident #1 did not receive their medication on at least one night on time because S8 stated S8 forgot which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Administrator shall provide additional training to all Staff responsible for medication assistance and provide proof to the department by the POC date.

Deadline recorded: Oct 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above water in room 246 and 247 measured 121.8 and 125.5 degrees] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/11/2024 Plan of Correction Administrator had water adjusted and is now within range. ***NO FURTHER ACTION REQUIRED***

Official classification

Type B

Official code

87161(a)(2)

Regulation authority

CCR

What the official deficiency says

87161 Resubmission of Application (a) A new application shall be made whenever there is any change in conditions or limitations described on the current license, including, but not limited to: (2) Any change in the licensee This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above. Facility changed the name of the facility from Alhambra Senior Villa to Savant of Alhambra without prior department approval. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/17/2024 Plan of Correction Facility will submit revised plan of operation as well as other documents required to change the name of the facility to LPA for approval by POC date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by Facility is in need of replacing the carpet or deep cleaning the carpet in all the hallways on all 3 floors, and in rooms #140, #109, #152. Room 104 was observed very unclean during the visit by LPA which pose/posses health and safety hazard to person in care.

Official plan of correction

Administrator will deep clean or replace all carpets in the hallways and in rooms #140, #109, #152. Also, will provide room 140 an overall cleaning.

Deadline recorded: Apr 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87003(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Facility is in need of replacing the carpet or deep cleaning the carpet in all the hallways on all 3 floors, and in rooms #140, #109, #152. Room 104 was observed very unclean during the visit by LPA which pose/posses health and safety hazard to person in care.

Official plan of correction

Administrator will deep clean or replace all carpets in the hallways and in rooms #140, #109, #152. Also, will provide room 140 an overall cleaning.

Deadline recorded: Apr 4, 2024. A deadline is not proof that correction was completed.