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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606945
Report Date: 05/17/2022
Date Signed: 05/20/2022 04:06:33 PM


Document Has Been Signed on 05/20/2022 04:06 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: 62DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Barbara Tyler, Administrator TIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Galarza, Valeria Maldonado, & Ashley Calderon conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs 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 5/3/2022 by Johnson Controls. Administrator certificate expires 7/13/2022.

The following was inspected and observed during the inspection:
  • 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.
  • Infection control signs, and other signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing.
  • Individual rooms, empty rooms, or SIU in Corona are designated isolation rooms.
  • Twenty one (21) resident rooms were inspected. Room # 211 & # 201 had plumbing issues. Room # 231 had broken vertical blinds.
  • Seven (7) centrally stored resident medication records were reviewed. Medication errors were observed. R1 was missing medication Acetaminophen 325 mg, Resident (R2) has prescribed medications on Physician's Report, but they were not listed on the Medication Administration Report. No proof that R2 refuses medication physician orders was documented. R2 had Acetaminophen 500 mg in the room, but it was not listed on the MAR.
  • 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.


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: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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Document Has Been Signed on 05/20/2022 04:06 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: 05/17/2022

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 # 211 & # 201 had plumbing issues, and room # 231 had broken vertical blinds, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Administrator shall submit proof of correction by POC due date.
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: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/20/2022 04:06 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: 05/17/2022

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, the licensee did not comply with the section cited above in that R1 was missing medication Acetaminophen 325 mg, Resident (R2) has prescribed medications on Physician's Report, but they were not listed on the Medication Administration Report. No proof that R2 refuses medication physician orders was documented. R2 had Acetaminophen 500 mg in the room, but it was not listed on the MAR; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2022
Plan of Correction
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Administrator shall submit a written plan stating how this deficiency will be correct. Facility shall contact resident physician. 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: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
LIC809 (FAS) - (06/04)
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