198601778-6-13-2024-28-AS-JVIS-D67UNQ-20240613154420

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601778
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:44:29 PM

Document Has Been Signed on 06/13/2024 03:44 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 UPTOWN WHITTIER		FACILITY NUMBER:	198601778
ADMINISTRATOR:	PRECIOSA (SUZIE) MAGPAYO		FACILITY TYPE:	740
ADDRESS:	13250 E PHILADELPHIA ST		TELEPHONE:	(562) 945-3904
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90601
CAPACITY:	280	CENSUS: 103	DATE:	06/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Administrator Suzie Magpayo		TIME COMPLETED:	03:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Wong 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 Administrator Suzie Magpayo who assisted LPA with the visit. The following 12 (CARE) tool domains were utilized during the inspection: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. LPA observed and reviewed the infection control plan 2. Physical Plant/Environmental Safety: The facility is a four story building. The facility does not have a dementia unit. A hospice waiver for 8 residents are in place. On the first floor, it includes: 26 residents rooms, TV lounge, reception area, executive director office, dining room, kitchen, coffee station, med-room, activity room, conference room, library, commercial laundry room and courtyard. On second floor, it includes 44 residents rooms, laundry room and sun deck. On third floor, it includes 44 residents rooms, laundry room, Wellness Center and residents' rest/puzzle area. On the forth floor, it includes 36 residents' rooms. laundry room and game area. LPA inspected rooms #102, #106, #107, #218, #231, #329, #333, #413, #421, #423, they all have required grab bar and non-skid mat in the bathroom. Each residents' bathrooms are clean, sanitary and in a operable condition. LPA tested all 10 residents room hot water temperature and its between 105 and 120 degrees F. which are within Title 22 regulation. LPA also inspected the smoke detectors and carbon monoxide detectors and they are all working well. Each residents room have the required furniture, bedding and sufficient lighting and closet space. The facility have a telephone services in the premises and each resident phone # are listed on the facility directory. Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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 UPTOWN WHITTIER	FACILITY NUMBER: 198601778
	VISIT DATE: 06/13/2024

NARRATIVE

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3.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 is approved for 8 residents. A fire clearance for 280 non-ambulatory residents. Liability Insurance in the amount of $2,500,000 per occurrence and $20,000,000 in total annual aggregate is in place. No Surety bond is in place. Facility does not handle resident finances.

4. Staffing: The facility has sufficient staffing in the facility to provide care and supervision to residents. All staff are over 18 years old. LPA observed there to be NOC shift staff available every day. Staff have updated first aid certificate and required emergency procedure training. Facility signal system is operational.

5. Personnel Record/Training's : The Administrator is Suzie Magpayo and her administrator certificate is currently active. All the facility staff have criminal background clearance and associated with the facility and the required training. Eight (8) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and all staff has an updated First Aid /CPR certificate.

6. Residents 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.

7. Residents Right-Information: RCFE complaint poster and Personal rights were observed and its posted near the entrance and reception area.

8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed.
An activity calendar is posted on the wall near the dining room and each resident would receive the activity calendar beginning of the month and also different activities poster also posted in the elevator . The facility also has a Resident Council.

9. Food Services: 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 residents' file. LPA observed list of residents with modified diets to be available to kitchen staff. LPA observed all food to be stored properly.
Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

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 UPTOWN WHITTIER	FACILITY NUMBER: 198601778
	VISIT DATE: 06/13/2024

NARRATIVE

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10. Incidental Medical and Dental Services: Ten (10) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided.

11. Disaster Preparedness: The facility has an updated Emergency and Disaster Plan and the evacuation chair at each stairway is in place. The last fire and disaster drill was conducted on 06/13/2024. The facility also has two alternative temporary shelter locations.

12. Resident with Special Health Needs: Five (5) residents are receiving home health services. There are four (4) resident receiving hospice care. No postural support residents currently reside in the facility. No half bed or full bed rails were observed in resident rooms. Individual Service Plans and Appraisals are on File. No residents have prohibited health condition.

No deficiencies were observed during the annual inspection. Exit Interview conducted and a copy of the report was provided to Administrator Suzie Magpayo.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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