197606945-4-19-2024-28-AS-NGAA-D4H27K-20240419170851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606945
Report Date: 04/19/2024
Date Signed: 04/19/2024 05:08:59 PM

Document Has Been Signed on 04/19/2024 05:08 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 WHITTIER		FACILITY NUMBER:	197606945
ADMINISTRATOR:	SANJAY KABADI		FACILITY TYPE:	740
ADDRESS:	8101 S PAINTER AVE		TELEPHONE:	(562) 698-0596
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90602
CAPACITY:	92	CENSUS: 43	DATE:	04/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Sanjay Kabadi, Executive Director		TIME COMPLETED:	05:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Galarza 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 Resident Engagement Coordinator Valerie Mendez. Health and Wellness Director Denise Bartley arrived shortly after. Executive Director Sanjay Kabadi arrived later. There are currently 43 elderly residents 60 years and older residing in the facility. The following 12 (CARE) tool domains were utilized during the inspection.

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:

An Infection Control Plan has been added to the Plan of Operation.
The facility has a Dementia Waiver in place and an approved Hospice Waiver for 12 residents.
A fire clearance for 74 non-ambulatory residents; of which 10 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 current with an expiration date of 12/31/2024.
No Surety bond is in place. Facility does not handle resident monies.

*Narrative continues next page.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

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: 04/19/2024

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. Beds had required bedding, linens, and mattress pads.
On 1/8/2024, Cintas Fire Protection conducted an inspection. Items of correction were identified, corrections are pending. 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, room #261 was [131.6DF], rm # 253 [127.7 DF], rm #241 [120.3 DF], rm# 236 [122.8 DF], rm #235 [123.5 DF], rm # 233 [ 124.4 DF], rm # 210 [124.4 DF]. A citation was issued.
Seventeen (17) rooms were inspected. Call light system and resident pendants were tested.

Staffing:

A total of 37 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificate expires 8/16/2024. Administrator provided proof that recertification training documents were submitted to CCL Recertification unit. Recertification process is 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.

Resident Records/Incident Reports:

A total of seven (7) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, Individual Service Plans, and medication records.
RCFE complaint poster and Personal rights were observed posted.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

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: 04/19/2024

NARRATIVE

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Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
An activity calendar is posted in the 1st floor hallway. 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. Records of physician's orders was reviewed in the kitchen.
At 12:12 PM LPA observed an open large size package of hot dogs being thawed in the kitchen sink where dirty dishes are rinsed, and uncovered plates of pie desserts were observed in the refrigerator.

Incident Medical and Dental:

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

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E was reviewed. Evacuation chair at each stairway is in place.
Records of resident Appraisal and Needs services plans are part of Emergency training.

Residents with Special Health Needs:

Two (2) residents are receiving hospice services. Ten (10) residents receive home health services.
Postural support physician orders are on file. Half bed rails for mobility assistance were observed in some resident rooms. No residents have prohibited health conditions.
Individual Service Plans and Appraisals are on file.

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

Exit interview was conducted with Sanjay Kabadi. A copy of the report and appeal rights was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/19/2024 05:08 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: 04/19/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that room #261 was [131.6DF], rm # 253 [127.7 DF], rm #241 [120.3 DF], rm# 236 [122.8 DF], rm #235 [123.5 DF], rm # 233 [ 124.4 DF], rm # 210 [124.4 DF, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/20/2024
	Plan of Correction
1 2 3 4	Administrator shall submit written proof of how the deficiency was corrected by tomorrow.

Type A

Section Cited

CCR

87555(b)(28)

General Food Service Requirements

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that at 12:12 PM LPA observed an open large size package of hot dogs being thawed in the kitchen sink where dirty dishes are rinsed and and uncovered plates of pie desserts were observed in the refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/20/2024
	Plan of Correction
1 2 3 4	Administrator shall submit by tomorrow written proof of how the deficiency will be corrected. Proof of staff training shall be submitted by Wednesday, 4/25/24.

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024

LIC809 (FAS) - (06/04)

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