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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606945
Report Date: 05/26/2021
Date Signed: 05/27/2021 08:04:25 AM

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:BROOKDALE CENTRAL WHITTIERFACILITY NUMBER:
197606945
ADMINISTRATOR:BARBARA TYLERFACILITY TYPE:
740
ADDRESS:8101 S PAINTER AVETELEPHONE:
(562) 698-0596
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:92CENSUS: 68DATE:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Barbara Tyler, AdministratorTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Barbara Tyler and explained the purpose of the visit. The facility does not have Dementia residents. A hospice waiver for 8 residents is in place. Facility is a 2-story building consisting of 73 resident rooms, 2 activity rooms, beauty salon, dining room, laundry room, and a courtyard patio area. The facility's last fire inspection was conducted on 4/11/2021 by Fire Safety Service Inc. Administrator certificate expires 7/13/2022. The following was inspected and observed during the inspection:
  • The main entrance of the facility is temporarily closed due to major plumbing issues on the 1st floor. Visitors are screened in the main entrance and then directed to enter the facility through the rear.
  • COVID-19 Infection Control Practices were observed in common areas, isolation rooms/wing areas, and resident rooms. COVID-19 infection control signs were observed in all common rooms, and hallways.
  • Facility has two (2) designated isolation areas.
  • Fourteen (14) resident rooms were inspected. Five (5) rooms did not have hand sanitizer.
  • Eight (8) centrally stored resident medication records were reviewed. Five (5) out of the 8 residents were missing medications.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. Lunch dining service was observed. All residents were socially distanced according to local public health guidelines.
  • Staff and resident files were not reviewed during today's visit.
Deficiencies were cited. See LIC809D.
Exit interview was conducted with Administrator. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: BROOKDALE CENTRAL WHITTIER
FACILITY NUMBER: 197606945
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on physical plant inspection of resident rooms and common areas a total of 5 rooms [106, 109, 129, 239, 247] out of 14 rooms inspected did not have hand sanitizer in the resident rooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2021
Plan of Correction
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Staff shall ensure all resident rooms have hand sanitizer. Submit a written plan of correction explaining how it was resolved.
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.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: BROOKDALE CENTRAL WHITTIER
FACILITY NUMBER: 197606945
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during medication review a total of 5 residents were missing prescribed medications. Wellness Director was provided a list of resident names and medications that were not found during review.
POC Due Date: 05/27/2021
Plan of Correction
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Administrator shall submit a written plan stating how this deficiency will be correct. Facility shall contact resident's MD and/or pharmacy and order medications. A RN or Pharmacist shall conduct staff in-service training regarding medication administration. Provide proof of in-service.
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.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021
LIC809 (FAS) - (06/04)
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