Other·June 12, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of The California Department of Public Health during the investigation of a complaint. Complaint Number: CA00566931. Representing the Department: HFEN#34178 This inspection was limited to the specific complaint and does not represent a full inspection of the facility. Two deficiencies were written for complaint number CA00566931.

F835 SS=D Administration CFR(s): 483.70

F835 05/31/2018 §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's administration failed to ensure the admission office and the medical record office follow facility's policies and procedures for a newly admitted resident for one of three closed LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 1 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055203 (X3) DATE SURVEY COMPLETED 05/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VILLAGE CARE CENTER 1428 S Marengo Ave Alhambra, CA 91803 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE records reviewed (Resident 1). This deficient practice resulted in the resident having no records in the facility's Admission and Discharge register logs, the medical record staffs were not aware of Resident 1's medical records, and the facility staffs had difficulty locating resident's medical records for resident's admission and discharge on 10/2/17. Findings: On 1/4/18, at 3:00 p.m., during an interview with the medical record assistant (MRA) and a concurrent record review of the facility's Admission register logs from 10/1/17 to 12/25/17, Discharge register logs from 10/1/17 to 12/20/17, and computerized admission records, MRA stated Resident 1 was not on the records. MRA stated, on review of the facility's computerized records, Resident 1 was discharged on 9/9/16. On 4/17/18 at 11:21 a.m., during an interview, the Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was a newly admitted resident that fell on the same day. CNA 1 stated assisting Resident 1 during resident's admission around 2:45 p.m.. On 4/17/18 at 3:05 p.m., during an interview, the medical record director (MRD) stated Resident 1 was in the facility for four hours. The MRD stated Resident 1 was not recorded in the facility's Admission and Discharge register logs. MRD stated facility had no medical records of Resident 1's for 2017. On 4/17/18 at 3:50 p.m., during an interview, the administrator stated the medical record office kept the daily census, and every resident admitted to the facility was documented on the Admission and Discharge register logs to notify FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 2 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055203 (X3) DATE SURVEY COMPLETED 05/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VILLAGE CARE CENTER 1428 S Marengo Ave Alhambra, CA 91803 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the administrator of new resident admissions and discharges. The administrator stated the information from the logs were used to update the facility's census. During the interview, the administrator stated, "I am not sure where Resident 1's medical record." The administrator called the director of nursing (DON) regarding Resident 1's medical record, and stated Resident 1's medical record was in a secured file area due to a pending litigation regarding resident. On 4/18/18 at 8:10 a.m., during an interview, the director of nursing (DON) stated the facility missed to document Resident 1 in the facility's Admission register logs and the daily census on 10/2/17. On 5/18/18 at 2:45 p.m., during an interview, the administrator stated Resident 1 did not have a medical record number for 10/2/17 admission and discharge; therefore, Resident 1 was not on the facility's Admission and Discharge register logs. A review of Resident 1's Admitting Information, dated 10/2/17 at 3:05 p.m., indicated Resident 1 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD, a lung disease characterized by increasing breathlessness) and asthma (condition causing the airways [the tubes that carry air in and out of the lungs] to narrow and swell). A review of Resident 1's Investigation and Conclusion record, dated 10/2/17, indicated, around 7:49 p.m., Registered Nurse 1 (RN 1) witnessed resident stood up to walk. RN 1 tried to catch resident but fell and landed on the floor backward. Resident 1 had "a bump on the occipital (back lower area of the head)." The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 3 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055203 (X3) DATE SURVEY COMPLETED 05/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VILLAGE CARE CENTER 1428 S Marengo Ave Alhambra, CA 91803 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE document indicated the physician was notified, and at 8:30 p.m., resident's saturation was 80% (oxygen level in the blood and the normal levels were 90% to 100%). The emergency services (911) was called and arrived at 8:40 p.m. Resident 1 was transported to a general acute care hospital (GACH 1). A review of the facility's policy and procedure titled, "Admission, Transfer, and Discharge Register," revised 6/08, indicated the medical records office maintains a current admission, transfer, and discharge register. The register contains, as a minimum, the following data: a. The date of the resident's admission, b. The resident's full name, c. The resident's medical record number, d. The age and sex of the resident, e. The resident's room assignment number, f. The name of the resident's Attending Physician, g. The place from which the resident was admitted (i.e. home, hospital), h. The date the resident was transferred or discharged, i. The reason for the transfer/discharge, j. The place to which the resident was transferred/discharged (i.e. hospital, home, room, etc.), and k. The length of the resident's stay. The policy and procedure indicated inquiries concerning admissions, transfers, and/or discharges should be referred to the medical records office. A review of the facility's policy and procedure titled, "Medical Record Numbers," revised 12/06, indicated a medical record number shall be assigned to a resident's medical records. Upon admission of a resident, a medical record number was assigned to assist in identifying the resident's records. The medical record number was recorded on all of the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 4 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055203 (X3) DATE SURVEY COMPLETED 05/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VILLAGE CARE CENTER 1428 S Marengo Ave Alhambra, CA 91803 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medical records. The assigned medical record number remains the same until the resident was discharged. Medical record numbers were assigned by the admission clerk and were recorded in the admission register. Should the resident be discharged and later admitted to the facility, a new medical record number would be assigned. A review of the facility's policy and procedure titled, "Retention of Medical Records," revised 12/06, indicated medical records shall be retained by the facility in accordance with current applicable laws. Medical record of discharged residents would be retained for a period of 10 years. A review of the facility policy and procedures titled, "Admission Policies," revised 12/06, indicated the primary purpose of our admission policies was to establish uniform guidelines for personnel to follow in admitting residents to the facility. It shall be the responsibility of the administrator, through the admissions department, to assure that the established admission policies, as they may apply, were followed by the facility.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 05/31/2018 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 5 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055203 (X3) DATE SURVEY COMPLETED 05/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VILLAGE CARE CENTER 1428 S Marengo Ave Alhambra, CA 91803 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 6 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055203 (X3) DATE SURVEY COMPLETED 05/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VILLAGE CARE CENTER 1428 S Marengo Ave Alhambra, CA 91803 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a newly admitted resident had a medical record number assigned and the resident's medical record was retained by the medical record office according to facility's policies and procedures for one of three closed records reviewed (Resident 1). This deficient practice resulted in the resident having no records in the facility's Admission and Discharge register logs, the medical record staffs were not aware of Resident 1's medical records, and the facility staffs had difficulty locating resident's medical records for resident's admission and discharge on 10/2/17. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 7 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055203 (X3) DATE SURVEY COMPLETED 05/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VILLAGE CARE CENTER 1428 S Marengo Ave Alhambra, CA 91803 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 1/4/18, at 3:00 p.m., during an interview with the medical record assistant (MRA) and a concurrent record review of the facility's Admission register logs from 10/1/17 to 12/25/17, Discharge register logs from 10/1/17 to 12/20/17, and computerized admission records, MRA stated Resident 1 was not on the records. MRA stated, on review of the facility's computerized records, Resident 1 was discharged on 9/9/16. On 4/17/18 at 11:21 a.m., during an interview, the Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was a newly admitted resident that fell on the same day. CNA 1 stated assisting Resident 1 during resident's admission around 2:45 p.m.. On 4/17/18 at 3:05 p.m., during an interview, the medical record director (MRD) stated Resident 1 was in the facility for four hours. The MRD stated Resident 1 was not recorded in the facility's Admission and Discharge register logs. MRD stated facility had no medical records of Resident 1's for 2017. On 4/17/18 at 3:50 p.m., during an interview, the administrator stated the medical record office kept the daily census, and every resident admitted to the facility was documented on the Admission and Discharge register logs to notify the administrator of new resident admissions and discharges. The administrator stated the information from the logs were used to update the facility's census. During the interview, the administrator stated, "I am not sure where Resident 1's medical record." The administrator called the director of nursing (DON) regarding Resident 1's medical record, and stated Resident 1's medical record was in a secured file area due to a pending FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 8 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055203 (X3) DATE SURVEY COMPLETED 05/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VILLAGE CARE CENTER 1428 S Marengo Ave Alhambra, CA 91803 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE litigation regarding resident. On 4/18/18 at 8:10 a.m., during an interview, the director of nursing (DON) stated the facility missed to document Resident 1 in the facility's Admission register logs and the daily census on 10/2/17. On 5/18/18 at 2:45 p.m., during an interview, the administrator stated Resident 1 did not have a medical record number for 10/2/17 admission and discharge; therefore, Resident 1 was not on the facility's Admission and Discharge register logs. A review of Resident 1's Admitting Information, dated 10/2/17 at 3:05 p.m., indicated Resident 1 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD, a lung disease characterized by increasing breathlessness) and asthma (condition causing the airways [the tubes that carry air in and out of the lungs] to narrow and swell). A review of Resident 1's Investigation and Conclusion record, dated 10/2/17, indicated, around 7:49 p.m., Registered Nurse 1 (RN 1) witnessed resident stood up to walk. RN 1 tried to catch resident but fell and landed on the floor backward. Resident 1 had "a bump on the occipital (back lower area of the head)." The document indicated the physician was notified, and at 8:30 p.m., resident's saturation was 80% (oxygen level in the blood and the normal levels were 90% to 100%). The emergency services (911) was called and arrived at 8:40 p.m. Resident 1 was transported to a general acute care hospital (GACH 1). A review of the facility's policy and procedure titled, "Admission, Transfer, and Discharge Register," revised 6/08, indicated the medical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 9 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055203 (X3) DATE SURVEY COMPLETED 05/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VILLAGE CARE CENTER 1428 S Marengo Ave Alhambra, CA 91803 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE records office maintains a current admission, transfer, and discharge register. The register contains, as a minimum, the following data: a. The date of the resident's admission, b. The resident's full name, c. The resident's medical record number, d. The age and sex of the resident, e. The resident's room assignment number, f. The name of the resident's Attending Physician, g. The place from which the resident was admitted (i.e. home, hospital), h. The date the resident was transferred or discharged, i. The reason for the transfer/discharge, j. The place to which the resident was transferred/discharged (i.e. hospital, home, room, etc.), and k. The length of the resident's stay. The policy and procedure indicated inquiries concerning admissions, transfers, and/or discharges should be referred to the medical records office. A review of the facility's policy and procedure titled, "Medical Record Numbers," revised 12/06, indicated a medical record number shall be assigned to a resident's medical records. Upon admission of a resident, a medical record number was assigned to assist in identifying the resident's records. The medical record number was recorded on all of the resident's medical records. The assigned medical record number remains the same until the resident was discharged. Medical record numbers were assigned by the admission clerk and were recorded in the admission register. Should the resident be discharged and later admitted to the facility, a new medical record number would be assigned. A review of the facility's policy and procedure titled, "Retention of Medical Records," revised FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 10 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055203 (X3) DATE SURVEY COMPLETED 05/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNNY VILLAGE CARE CENTER 1428 S Marengo Ave Alhambra, CA 91803 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/06, indicated medical records shall be retained by the facility in accordance with current applicable laws. Medical record of discharged residents would be retained for a period of 10 years. A review of the facility policy and procedures titled, "Admission Policies," revised 12/06, indicated the primary purpose of our admission policies was to establish uniform guidelines for personnel to follow in admitting residents to the facility. It shall be the responsibility of the administrator, through the admissions department, to assure that the established admission policies, as they may apply, were followed by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: M7MT11 Facility ID: CA950000061 If continuation sheet 11 of 11