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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606945
Report Date: 05/18/2023
Date Signed: 05/18/2023 05:00:30 PM


Document Has Been Signed on 05/18/2023 05:00 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
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: 46DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Denise Bartley, Health/Wellness Director TIME COMPLETED:
05:05 PM
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Licensing Program Analysts (LPAs) Galarza and Joe Katrdzhyan conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Business Office Manager Christina Schoech and Wellness Director Denise Bartley. There are currently 46 elderly residents 60 years and older residing in the facility. Two (2) residents are receiving hospice care.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.


Operational Requirements:
  • A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan.
  • The facility does not have a Dementia Waiver in place. A Hospice Waiver for 8 is approved.
  • A fire clearance for 85 non-ambulatory residents; of which 7 may be bedridden is in place.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place.
  • No Surety bond is in place. Facility does not handle resident monies.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
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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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
VISIT DATE: 05/18/2023
NARRATIVE
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Physical Plant/Environment Safety:
  • 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 interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents.
  • On 2/8/2023, LA County FIre Department conducted an inspection to correct the violations identified in the Fire Department report. The sprinkler system, alarms, fire connections, and kitchen hood system were inspected. The facility has fully charged fire extinguishers.
  • Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit, and kitchen hot water faucets measured below 125 DF. Rooms 229 (120.3 DF), 235 (120.9 DF), 243 (122.3 DF), 251 (121.8 DF), 252 (122.1 DF), 257 (121.2 DF)
  • Room 117 entrance wall was in disrepair.

Staffing:
  • A total of 33 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator on record is not current. A new Administrator began working at the facility on May 15, 2023. Documents are pending.
  • Staff have criminal background clearance and training.
  • Seven (7) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed. One (1) out of seven (7) staff did not have current 1st Aid/CPR training.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
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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
VISIT DATE: 05/18/2023
NARRATIVE
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Resident Records/Incident Reports:
  • A total of ten (10) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.
  • RCFE complaint poster and Personal rights were observed posted. The Incident report binder was reviewed.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar is posted by the game room.
  • The facility has a Resident Council.

Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • Physician orders for modified diets are on file.
  • Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:
  • Seven (7) centrally stored resident medications were reviewed; containing 30-day supply of medications.
  • Medical and dental transportation is provided.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place.
  • Records of resident Appraisal and Needs services plans are part of Emergency training.


See next page
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/18/2023 05:00 PM - It Cannot Be Edited

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: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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
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Based on observation, the licensee did not comply with the section cited above in that rooms 229 (120.3 DF), 235 (120.9 DF), 243 (122.3 DF), 251 (121.8 DF), 252 (122.1 DF), 257 (121.2 DF) had water temperature that exceeded above 12 DF; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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Staff shall adjust the hot water temperature in the building and submit a temperature log (tested 3 times a day) for the above mentioned rooms.
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the kitchen sink faucets measured below 125 DF [123.4, 124.9]; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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Staff shall adjust the hot water temperature and ensure the hot water temperature in the kitchen is at least 125 DF, and hot water sink areas are identified by warning signs. Submit proof of correction.
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: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 05/18/2023 05:00 PM - It Cannot Be Edited

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: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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 requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that room 117's walls were in disrepair; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2023
Plan of Correction
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Staff shall submit picture proof evidence of room repairs.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one (1) staff did not have current 1st Aid/CPR training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2023
Plan of Correction
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Staff shall submit proof of 1st Aid/CPR training by POC due date.
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: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/18/2023 05:00 PM - It Cannot Be Edited

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: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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 ... 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:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that resident (R1's) furosemide 40 mg was not administered as prescribed (1/2 the pill remained in the bubble pack) and was missing Hydralazine HCL 25 mg, and R2 was missing fish oil/D3 360-1200 mg AM bubble pack, and bedtime Tylenol 325 mg bubble packs; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
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Facility called the pharmacy and ordered the medications. Submit proof of correction by tomorrow.
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: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


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
VISIT DATE: 05/18/2023
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Residents with Special Health Needs:
  • Eleven (11) residents are receiving home health services. Two (2) resident receive hospice care.
  • Postural support physician orders are on file.
  • No half bed rails for mobility assistance were observed in resident rooms.
  • Individual Service Plans and Appraisals are on file.
  • No residents have prohibited health conditions.


Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Denise Bartley. 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: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7