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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601660
Report Date: 09/15/2023
Date Signed: 09/15/2023 01:46:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2021 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210628090036
FACILITY NAME:POSADA AT WHITTIERFACILITY NUMBER:
198601660
ADMINISTRATOR:JANETTE HILLFACILITY TYPE:
740
ADDRESS:8120 S PAINTER AVETELEPHONE:
(562) 945-2651
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:0CENSUS: 89DATE:
09/15/2023
UNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Diana Bautista, AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Resident's care needs are not being met.
Staff are not responding to call button timely.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit regarding the above allegations. The purpose of the visit was discussed with med-tech staff. Administrator Diana Bautista arrived shortly after.

The investigation consisted of: On 7/7/2021, a physical plant tour of the facility common areas, Memory Care unit, and resident rooms [116, 201, 205, 212, 217, 225, 306, 310, 313, 317, 319, 321, 325] was conducted. Call signal was tested in 3 rooms. Installation of new carpet in facility hallways was observed. Pictures were taken of rooms that need repairs. Staff (S1-S7) and residents (R1-R2) were interviewed. Resident (R1's) file documents were obtained [Identification and Emergency Information, Physician Report, Needs and Services Plan, resident roster, LIC 500 Personnel Report copies of cleaning responsibilities and personal care assistant job description were obtained. During today's visit, a physical plant inspection of common areas/random rooms was conducted, as well as interviews with staff (S8) and residents (R3- R10).

****Report narrative conitnues next page.****
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20210628090036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: POSADA AT WHITTIER
FACILITY NUMBER: 198601660
VISIT DATE: 09/15/2023
NARRATIVE
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Allegation: Resident's care needs are not being met. It was alleged that facility staff failed to meet resident (R1's) needs because the resident was seen wearing the same shirt with food stains on it for at least one week, was only wearing incontinence underwear while in bed, was not being given denture cream, staff left towels with feces in the bathtub, and the floor was often dirty. Per file review and staff interviews, the resident required full assistance with activities of daily living (ADLs) i.e. dressing, toileting, and bathing. A total of eight (8) staff were interviewed, of which 3 staff stated that the facility had major staffing shortages i.e. on weekends there was only 1 caregiver on schedule, staff were working double shifts, and agency staff were used as well. According to staff, residents are supposed to have a change of clothes daily, are bathe twice a week and/or as needed, and incontinent residents should be checked every 2 hours. In regards to R1, staff stated that the resident was able to communicate needs. Resident (R1's) primary caregivers confirmed that several weeks in June 2021/early July 2021, when staff began their shift they noticed that R1 did not have pajamas pants on in bed and was still wearing pants from the previous day. There were days were the resident was observed laying in bed with only incontinence underwear. Staff stated that these incidents were likely due to staff shortages, and caregivers may have left the resident only wearing an incontinence diaper because it is easier and faster to change the resident due to time constraints and work load pressure. It was reported that caregivers justified these incidents by saying that they did not have time and/or the resident refused to be changed. However, per R1 appraisals the resident is bed bound and needed full assistance. Family visited the resident on several occasions and noted the resident's ADL needs were not being met. Pictures were taken depicting the resident wearing the same clothes several days in a row, and being left in bed only wearing incontinence diapers. Residents interviewed stated things have improved since 2021, and overall staff were meeting their needs if there weren't any staff shortages.

Allegation: Staff are not responding to call button timely. It is alleged that the call light system is operable, but staff were taking longer than 10 minutes to respond to resident (R1's) requests, and/or sometimes forgot to check on the resident. The issue was primarily happening on weekends. The findings indicate that although caregiver staff are to respond within 5-7 minutes to call light requests, in late June 2021 and early July 2021, the facility was short staffed and there were occasions in which there was only 1 caregiver and 1 med-tech assisting Assisted Living (AL) residents. Staff reported that resident (R1) yelled for assistance instead of pulling the call light string. However, during the 7/7/2021 inspection it was noted the call light base was across the room from R1's bed. Staff placed an extra long string around the walls and attached a plush stuffed animal to it so that the resident can grab and call for assistance. All staff stated they tried to respond as soon as possible, but some residents require 2 staff assist, therefore, it took longer to assist other residents. Two other rooms [#320 & #321] call light system was inoperable for months. Staff acknowledged that in July 2021, sometimes were taking up 30 minutes to respond to residents as a result of staff shortages. The two residents that were interviewed in 2021 stated that staff were taking an unusually long time to respond to call light requests. The majority of the residents interviewed today, no longer recall call light response times in 2021. Based on staff interviews, there is sufficient evidence to corroborate the allegation.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20210628090036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: POSADA AT WHITTIER
FACILITY NUMBER: 198601660
VISIT DATE: 09/15/2023
NARRATIVE
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Allegation: Facility is in disrepair. It was alleged that resident rooms and bathrooms were not being cleaned, hallway carpets were dirty, and the overall condition of the facility showed disrepair. Based on interviews conducted with eight (8) staff, all staff confirmed the allegation. According to interviews, the facility had plumbing issues, many rooms needed repairs because the walls and flooring/carpets were damaged and/or dirty, there were leaks in the kitchen area, laundry washers were often in disrepair, and the facility did not have a maintenance staff person for several months. Resident interviews revealed that some resident rooms had holes in the walls that were not repaired for close to 2 years. During the physical plant inspection on 7/7/2021, LPA conducted a physical plant tour of the common areas, Memory Care Unit, and 13 resident rooms. Observations made confirmed the allegation. Room door frames and lower panel area of doors were in disrepair and extremely dirty. Rooms 205, 217, 317 had holes in the shower/bathtub that were covered with duct tape, peeling bathtub baseboards, and paint peeling in the bathroom walls. Room #313 main entrance door/fire door was chipped in the upper corner, electrical outlet did not have a cover, and the room walls were in need of painting. Room #225 had trash everywhere on the floor, and the floors were dirty. The majority of the resident rooms inspected that had carpet were dirty and very stained. Photographs were taken of the rooms and facility areas were in disrepair. Residents stated the majority of repairs have now been completed. During today's inspection, it was observed that a new call light base was installed close to R1's bed, and the room appeared clean. However, room 301's interior door knob handle is in disrepair, and rooms 302 and 316 are missing bathroom lights.

Based on interviews conducted and observations made, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per Title 22, deficiencies are cited.

Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210628090036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: POSADA AT WHITTIER
FACILITY NUMBER: 198601660
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2023
Section Cited
CCR
87464(f)(4)
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Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
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Administrator agrees to submit proof of staff training regarding regulation 87464, and will ensure staffing needs are met.
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Based on record review and interviews conducted resident (R1) requires full assistance with ADLs, and due to staffing shortages the resident was not being dressed or checked according to resident's needs in June 2021 & July 2021 as result of staffing shortages; which posed potential health and safety risks to persons in care.
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Type B
09/22/2023
Section Cited
CCR
87303(i)(1)
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Maintenance and Operation. Facilities licensed for 16 or more and/or facilities that have separate floors or buildings shall have a signal system which meets specified requirements.Operate from each resident's living unit.
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Administrator stated the signal system in rooms 320 & 321 was repaired. Administrator agreed to submit a written plan of correction stating how the deficiency was corrected.
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Based on interviews conducted, the facility failed to have an operable call light system for several months in rooms # 320 & #321, and R1's call light string was not observed accessible during 7/7/21 visit; which posed a potential health and safety risk to resident.
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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: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210628090036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: POSADA AT WHITTIER
FACILITY NUMBER: 198601660
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2023
Section Cited
CCR
87303(a)
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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 was not met by evidence of:
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Administrator agreed to submit a written plan of correction stating how 2021 repair issues were resolved, and proof the rooms identified today in need of repair have had repairs completed.
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Based on observation during physical plant inspection (7/7/21) as well as interviews conducted, resident rooms were in disrepair with holes on walls, dirty walls, plumbing issues, and facility hallways had heavily stained carpets; today room 301, 302, 316 need repairs; which poses a potential health and safety risk to residents in care.
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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: 09/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5