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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606945
Report Date: 01/13/2023
Date Signed: 01/13/2023 09:52:08 AM


Document Has Been Signed on 01/13/2023 09:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 52DATE:
01/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Barbara Tyler TIME COMPLETED:
09:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted a unannounced case management visit o cite for deficiencies related to complaint investigation control # 28-AS-20210616095611. LPA met with Administrator Barbara Tyler and discussed the purpose of the visit.

On the initial complaint visit conducted on 12/20/2021, LPA conducted a health and safety check. LPA toured the facility with Denise Bartley and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Restrooms, handwashing basins, toilets and bathtub/showers are operable. There are no immediate health and safety concerns. During today's visit. LPA also gathered information from Resident#1 (R1) file and reviewed two other residents' file. The following documents were collected which included: staff and resident roster, R1's resident information/emergency contact sheet, physician report dated on 10/12/21, preplacement appraisal information, physician/healthcare provider order sheet and care profile. The complaint was accepted by the CCL IB investigation Unit and assigned to IB Investigator Garcia. IB investigator Garcia conducted and complete investigation which includes interviews with the R1’s relative, six facility staff, facility residents, administrator, physical therapist. IB Investigator Brian also obtained Hospital Record and police report.

During the investigation, IB Investigator Garcia reported that on December 11, 2021, R1 complained of right-side pain and pain across her chest area. R1 also attributed the pain to have occurred while the caregiver was assisted during her morning routine. The facility health and wellness director examined R1 and noted no bruising, swelling, redness to the area that R1 complained about. Facility did not seek any medical attention by a physician.

(See LIC 809C for continuation)
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BROOKDALE CENTRAL WHITTIER
FACILITY NUMBER: 197606945
VISIT DATE: 01/13/2023
NARRATIVE
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On December 12, 2021, R1 continued to complain of pain to the same area. On December 13, 2021, resident continued to complaint of the same pain to her right side and pain across the chest, especially when moving around. Facility staff called R1’s physician and requested PRN medication but staff never received any call back from R1’s physician. On December 15, 2021, R1’s home health nurse went to the facility to provide physical therapy for R1 and noticed R1 was complaining of chest pain. The therapist immediately called R1’s physician and advised to send R1 to the emergency room for evaluation. R1 was transported to the Emergency Room via 911 right away, and R1 was diagnosed with rib fracture and elevated potassium level.

Per Title 22, Division, 6, Chapter 8 has been cited. See LIC 809D.

Exit interview was held with Administrator. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/13/2023 09:52 AM - 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
GREATER LA AC/SC, 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: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2023
Section Cited

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87466 Observation of the Resident-The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
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Administrator will ensure residents regularly observed for changes in physical, mental and emotional and social functioning and Administrator will retrain the staff on regularion and send the training log to LPA by POC due date.
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When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
The requirement was not met as evidenced by R1 was not sent to hospital in a timely manner
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Type B
01/30/2023
Section Cited

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87405 Administrator - Qualifications and Duties d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Administrator will ensure to meet by the qualification. Administrator will send a plan and submit proof of correction by POC due date.
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(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. The requirement was not met as evidenced by:
Administrator did not follow up with staff about R1's condiiton.
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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: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
LIC809 (FAS) - (06/04)
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