Sunny Village Care Center
SUNNY VILLAGE CARE CENTER in ALHAMBRA, CA — inspection on March 26, 2026.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 3/26/2026 at 10:15 AM with the Administrator, the Administrator stated the Residents' Rights are not currently posted in the facility.
The Administrator stated the facility policy required for the Residents' Rights to be posted.
During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 2/2021, the P&P indicated federal and state laws guarantee certain basic rights to all residents that include resident's right to be notified of the medical condition and communication with and access to people and services, both inside and outside of the facility.
The facility policy stated copies of the residents' rights are posted throughout the facility.
During a review of Resident 37's MDS, dated [DATE], the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making.
The MDS also indicated the resident was dependent (helper does all of the effort.
Resident does none of the effort to complete the activity.
Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene.
The MDS indicated Resident 37's hearing is adequate (no difficulty in normal conversation).
During a concurrent observation and interview on 3/23/2026 at 9:30 AM, Resident 37 stated he is hard of hearing and has difficulty hearing the surveyor.
During an interview on 3/26/2025 at 1:36 PM, Registered Nurse Supervisor (RNS) stated Resident 37 is hard of hearing.
During a concurrent interview and record review on 3/26/2026 at 12:08 PM, Resident 37's MDS, dated [DATE], was reviewed.
The Director of Nursing (DON) stated Resident 37's MDS indicated Resident 37 has adequate hearing.
The DON also stated Resident 37 was inaccurately assessed since Resident 37 does have difficulty hearing during normal conversations.
The DON added it is important for the resident to have an accurate MDS because it can affect the resident's plan of care and may result in services or treatment not provided in accordance with the resident's needs.
During a review of the facility's Policy and Procedure titled Resident Assessments, revised 3/2022, the P&P indicated the resident assessment form must attest to the accuracy of the MDS.
The P&P also indicated the results of the assessments are used to develop, review and revise the resident's comprehensive care plan.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool), dated 12/26/2025, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making.
The MDS also indicated the resident was dependent (helper does all of the effort.
Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene.
During a review of Resident 37's progress notes, dated 9/1/2025 at 1:31 PM, the progress notes indicated RP cancelled Resident 37's ENT doctor appointment.
During a review of Resident 37's Care Plan with focus impaired communication related to impaired hearing, revised 3/2026, the Care Plan indicated Resident 37's needs will be attended and met.
The care plan did not indicate an intervention for RP's refusal for Resident 37 to see an ENT doctor.
During an observation on 3/23/2026 at 9:30 AM, Resident 37 stated he is hard of hearing and cannot hear the surveyor talk.
During an interview on 3/24/2026 at 11:07AM, Social Services Director (SSD) stated Resident 37's RP refused for the resident to see an ENT doctor.
During an interview on 3/25/2026 at 10:44 AM, Resident 37's Care Plan with focus impaired communication related to impaired hearing, revised 3/2026, was reviewed.
The Director of Nursing (DON) stated Resident 37's care plan did not include the RP's refusal of an ENT, and it should have included the RP's refusal for Resident 37 to see an ENT doctor.
The DON also stated, it is important to have interventions for RP's refusal so the facility can provide interventions for the continuity of care.
During a review of the facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Plans, revised 3/2022, the P&P indicated assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
During a review of Resident 8's History and Physical (H&P), dated 1/30/2026, the H&P indicated the resident has the capacity to understand and make decisions.
During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), dated 2/9/2026, the MDS indicated the resident is dependent (helper does all of the effort.
Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with sit- to- lying, lying- to- sitting on side of bed, chair/bed to chair transfer, toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear.
During a concurrent observation in Resident 8's room and interview on 3/23/2026 at 8:37 AM, a communication board written in Language 2 was at Resident 8's bedside. Resident 8 stated there are not many people in the facility the resident can communicate with. Resident 8 also stated she does not use the communication board provided to her because she does not understand it. Resident 8 stated she does not speak Language 2, but speaks Language 1.
During a concurrent observation in Reisdent 8's room and interview on 3/24/2026 at 11 AM, Registered Nurse Supervisor 1 (RNS 1) stated Resident 8's communication board was written in Language 2, and it should be in Language 1. RNS 1 also stated Resident 8 would not be able to communicate her needs to the facility since the communication board is not fit for Reisdent 8.
During an interview on 3/26/2026 at 11:58 AM, the Director of Nursing (DON) stated Resident 8 should not be provided with a Language 2 communication board but with Language 1.
The DON also stated it is to ensure Resident 8 is able to communicate the resident's needs to the facility staff.
During a review of the facility's undated Policy and Procedure (P&P) titled Communication with Limited English Proficient Persons, the P&P indicated, it is the facility policy to ensure that persons with limited English proficiency are identified and that the facility is capable of communicating information to such person efficiently.
The P&P also indicated if needed, the facility will provide a communication board at the bedside, and/or with patients to provide proper communication methods and translation.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
During a concurrent interview and record review on 3/26/2026 at 8:30 AM, Resident 8's Care Plan with focus risk for fall and injury, dated 11/13/2025, was reviewed.
Registered Nurse Supervisor 1 (RNS 1) stated the care plans indicated the resident should be monitored more frequently for her needs, comfort, safety and whereabouts. RNS 1 also stated frequently means every hour.
During a concurrent interview and record review on 3/26/2026 at 11:48 AM, Resident 8's Care Plan with focus risk for fall and injury, dated 11/13/2025, was reviewed.
The DON stated frequently in the care plan means every hour and the monitoring was not done every hour.
During a review of the facility's P&P titled Safety of Residents, revised July 2017, the P&P indicated our individualized, resident centered approach to safety addresses safety and accident hazards for individual residents.
The P&P also indicated the care team shall target interventions to reduce individual risk including adequate supervision and assistive devices.
During the same concurrent interview and record review on 3/26/2026 at 11:48AM, the facility's P&P titled Managing Fall and Fall Risk, revised 3/2018, was reviewed.
The P&P indicated the facility will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.
The DON stated a fall prevention plan indicated in the policy is a care plan to help prevent future falls.
During the same interview on 3/26/2026 at 11:48AM, the facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Plans, revised 3/2022, was reviewed.
The P&P indicated the care plans describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
The DON) stated according to the policy, the facility would need to follow the interventions in the care plan to prevent future falls.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
into the digestive system as a liquid) Feedings- Safety Precautions, dated 11/2018 was reviewed.
The purpose of the P&P is to ensure the safe administration of enteral nutrition.
The facility will remain current in and follow accepted best practices in enteral nutrition.
Date and time formula was prepared and rate of administration should be checked to prevent errors.
The DON stated that tube feeding is ordered to maintain a resident's steady weight and to provide nutrition.
The DON stated that if the tube feeding is not running as ordered, the resident may not receive adequate nutrition and as a result, may lead to weight loss, skin breakdown, abnormal labs, and decline in health condition.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
During a
policy was to help staff develop interventions that are consistent with the resident's goals and needs.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
During a review of Resident 87's Minimum Data Set (MDS- a resident assessment tool), dated 3/13/2026, the MDS indicated Resident had intact cognitive (ability to understand and make decisions) skills for daily decision-making.
The MDS indicated Resident 87 was partial/moderate assistance (helper does less than half the effort) with toileting and personal hygiene, bathing/showering self, and setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating and oral hygiene.
During a review of Resident 87's Care Plan, related to ESRD, initiated 6/18/2025, the Care Plan indicated Resident 87's dialysis access site as her left upper arm arteriovenous (AV) shunt (a connection between an artery and a vein used for hemodialysis).
The care plan also indicated the interventions were to check resident's access site pre and post dialysis and to communicate with the hemodialysis (HD) center regarding resident's pre and post dialysis status.
During an interview on 3/24/2026 at 7:54 AM with Resident 87, Resident 87 stated she has an AV shunt in her left arm, and she goes to dialysis twice a week.
During a concurrent interview and record review on 3/26/2026 at 8:50 AM with Registered Nurse Supervisor 3 (RNS 3), Resident 87's Nurses Dialysis Communication Records, from 3/1/2026 through 3/26/2026 were reviewed.
The Nurses Dialysis Communication Records dated 3/13/2026, 3/16/2026, 3/20/2026, and 3/23/2026 indicated Resident 87 with a dialysis access site to her left upper arm (LUA).
The Nurses Dialysis Communication Records did not reflect an assessment of the LUA access site and/or dressing. RNS 3 stated licensed nursing staff should have been assessing and documenting on the Nurses Dialysis Communication Records if Resident 87's access site had redness, swelling, drainage, and/or if the dressing was intact or present. RNS 3 further stated, the access site should be assessed to see if there are any changes to it so that the doctor can be informed and other interventions can be provided.
During an interview on 3/26/2026 at 1:56 PM with the Director of Nursing (DON), the DON stated per facility protocol, the licensed nursing staff need to assess the residents receiving dialysis. DON stated the residents' dialysis access site before and after dialysis should be assessed and assessment should be documented on the Nurses Dialysis Communication Record to ensure the staff at the dialysis center will know the condition of the resident.
During a review of the facility's P&P titled, Care of a Resident with End-Stage Renal Disease, revised 9/2010, the P&P indicated that residents with ESRD will be cared for according to current recognized standards of care and that the facility will communicate the status of the resident prior to going to dialysis center by completing the information in the communication form to the dialysis center.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 3/9/2025, the MDS indicated the resident had intact cognitive skills for daily decision making.
The MDS also indicated Resident 20 required partial/moderate assistance (helper does less than half the effort.
Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene.During a medication administration observation on 3/25/2026 at 9:10 AM, Licensed Vocational Nurse 5 (LVN 5) was observed not checking Resident 20's arm band to identify the resident prior to medication administration.
During an interview on 3/25/2026 at 9:30AM, LVN 5 stated she did not and should have checked Resident 20's arm band prior to medication administration. LVN 5 stated it was important to identify the resident prior to medication administration to ensure it is the right resident.
During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated 10/2024, the P&P indicated the individual administering medications verify the resident's identity before giving the resident his/her medications.
Methodes of identifying the residents include checking identification band.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
During a concurrent observation and interview on 3/23/2026 at 8:16 AM in the facility kitchen with the Kitchen Supervisor (KS), the following was observed in the dry food storage area: a. A scoop device was sitting right on top of the rice inside the container of jasmine rice. b. A big jar of red jello had no label to indicate the item name, date it was prepared and was not labeled with the use by date. KS stated in accordance with the facility policy, all food items should be labeled with the date it was opened or prepared and the food item should be labeled with the use by date once opened. KS also stated the food items should be labeled with their specific name of the food. KS stated scoop device must be kept hanging inside the bin and not on top of the rice/ food. KS stated it is very important to label and store food items per policy to ensure that the food items are safe to eat for the residents.
During a review of the facility's P&P titled Labeling and Dating of Foods, undated, the P&P indicated, all food items in the storeroom, refrigerator, and freezer need to be labeled and dated.
The P&P also indicated, newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines included in the P&P.
The P&P also indicated all prepared foods need to be covered, labeled, and dated.
During a review of the facility's P&P titled, Sanitization, revised October 2008, the P&P indicated, scoop device being used to scoop the rice should be placed in the proper place like hanging inside the bin but not on top of the rice.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
During an observation on 3/24/2026 at 10:53 AM in the facility's parking lot's dumpsters area, there were two out of three blue dumpsters with lids left wide open.
One of the blue dumpsters is for the recycled boxes with the lid closed, the other two blue dumpsters are for the kitchen and facility waste with both lids were left wide open.
During an interview on 3/24/2025 at 11:02 AM with the Maintenance Supervisor (MS), MS stated per the facility's P&P, all the dumpsters' lids were supposed to be kept closed at all times to keep out flies and rodents and to prevent transfer of disease.
During a review of the facility's P&P titled, Garbage and trash, revised July 2024, the P&P indicated the main dumpster cover should be always closed.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
record and that the medical record should facilitate communication between the interdisciplinary team
Administration, revised 10/2010, the P&P indicated after giving oxygen, the following should be
title of the individual who performed the procedure.The rate of oxygen flow, route and rationale.The frequency and duration of the treatment.The reason for the PRN (given as needed or requested) administration.How the resident tolerated the procedure.The signature and title of the person recording the data.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was originally admitted to the facility on [DATE]. 2.
During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was originally admitted to the facility on [DATE].
During a concurrent interview and record review on 3/24/2026 at 1:17 PM with the Admissions Assistant (AA), Resident 51 and 87's Resident-Facility Arbitration Agreements, dated 5/18/2023 and 11/26/2024 were reviewed. Resident 51 and Resident 87's Arbitration Agreements both failed to include language for the provisions of a neutral arbitrator that would be agreed upon by both parties and/or for the selection of a venue that is convenient to both parties (residents and facility).
The AA stated neither Resident 51's nor Resident 87's arbitration agreements included for a neutral arbitrator agreed upon by both parties or that a convenient venue to both the residents and facility will be provided.
The AA further stated that he was not aware of the specific things that needed to be included in the arbitration agreements and he would need to speak to the Director of Admissions (DA).
During an interview on 3/24/2026 at 1:30 PM with the DA, the DA stated she was not aware that the provision of a convenient venue and the provisions for a neutral arbitrator agreed upon by both parties needed to be included in the arbitration agreements offered to residents for signature.
The DA stated it was important for the arbitration agreements offered to residents to include for the provision of a neutral arbitrator that was agreed upon by both parties and the provision of a convenient location to ensure that residents are aware at the time they are making a decision so that they know there is no bias (the action of supporting or going against a particular person or thing in an unfair way) in the arbitration process.
During a review of the facility's policy and procedure (P&P) titled, Resident admission Agreement- Consents- admission & General- Reference Health Insurance Portability and Accountability Act (HIPAA - a US federal law designed to protect sensitive patient health information from being disclosed without consent), revised 2/2/2023, the P&P indicated the facility's binding arbitration agreement will provide for the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that is convenient to both parties.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803
During a review of Resident 85's admission Record, the admission Record indicated Resident 85
included dementia (a progressive state of decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and hypertensive heart disease (heart complications caused by high blood pressure that is present over a long time).
During a review of Resident 85's MDS, dated [DATE], the MDS indicated Resident 85 had severely impaired cognitive skills for daily decision making.
The MDS indicated Resident 85 required partial/moderate assistance (helper does less than half the effort) with oral, toileting and personal hygiene, bathing and dressing, and setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating.
During a review of Resident 85's Order Summary Report, dated 3/25/2026, the Order Summary Report indicated a physician's order, dated 11/1/2025 for resident to receive oxygen two (2) liters (L- a unit of measurement in volume) per minute via nasal cannula as needed to maintain oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) at 92 percent (%).
Call medical doctor (MD) if there is no improvement in 02 sat level, with an order start date of 11/1/2025.
During a concurrent observation and interview on 3/25/2026 at 10:44 AM with Licensed Vocational Nurse 1 (LVN 1) at Resident 85's bedside, the resident's nasal cannula tubing, labeled with a date of 3/15/2026 was observed connected to a portable oxygen tank. LVN 1 stated the date on the nasal cannula indicates when tubing was last changed. LVN 1 stated Resident 85's tubing should have been changed at least weekly [3/22/2026] per facility protocol to maintain infection control. LVN 1 further stated it was important to change the nasal cannula to prevent Resident 85 from using dirty oxygen tubing, which could cause a respiratory infection affecting his nose and/or lungs.
During a concurrent interview and record review on 3/25/2026 at 4:30 PM with Registered Nurse 2 (RN 2), Resident 85's medical record from 3/1/2026 through 3/25/2026 was reviewed.
The medical record failed to indicate any documented evidence that Resident 85's oxygen tubing was changed after 3/15/2026. RN 2 stated per facility protocol, oxygen tubing (including nasal cannulas) is changed within 7 days and as needed if dirty and should be labeled with the date it was changed. RN 2 stated it was necessary to change the tubing to provide the best standard of care and ensure tubing stays clean for residents' use. RN 2 further stated if Resident 85 was to use contaminated tubing, that could lead to a preventable respiratory infection.
During an interview on 3/26/2026 at 1:56 PM with the Director of Nursing (DON), the DON stated per facility policy, oxygen tubing is changed every 7 days and as needed to prevent tubing contamination.
During a review of the facility's P&P titled, Oxygen Administration, revised 10/2010, the P&P indicated for oxygen tubing to be changed weekly.
055203 03/26/2026
Sunny Village Care Center 1428 S.
Marengo Ave.
Alhambra, CA 91803