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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603162
Report Date: 01/24/2025
Date Signed: 01/24/2025 03:34:44 PM

Document Has Been Signed on 01/24/2025 03:34 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:WHITTIER GLEN ASSISTED LIVINGFACILITY NUMBER:
198603162
ADMINISTRATOR/
DIRECTOR:		BARBA AGUIRRE, ITZAYANAFACILITY TYPE:
740
ADDRESS:10615 JORDAN RDTELEPHONE:
(562) 943-3724
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 93CENSUS: 74DATE:
01/24/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:01 PM
MET WITH:Kathleen McDonald - Wellness DirectorTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced case management visit in response to Serious Incident Report (SIR) dated 1/2/2025 that describes the passing of Client #1 (C1). LPA met with Kathleen McDonald, Wellness Director for the facility, and explained the purpose of the visit.

LPA Interviewed Staff #1 (S1) during the visit. LPA attempted to interview Staff #2 (S2), however they were not available. S1 explained on the day of the incident they were notified by other residents that C1 was choking and needed medical assistance. S1 observed that C1 could not speak and was struggling to breathe, and therefore began performing sets of Heimlich Maneuvers before beginning cardiopulmonary resuscitation (CPR). S1 stated that they began performing chest compressions on C1 as directed by the 911 operator, and S1 stated that they could not see any food in C1's throat when asked by the operator. Emergency Medical Technicians (EMT) arrived on the scene and took over chest compressions along with administering an Automatic External Defibrillator (AED) for 10 - 15 minutes until C1 was declared deceased.

LPA obtained C1's FACE Sheet, Most Recent Physician's Report, a meal menu for the week of 12-29/2024 - 1/4/2025, and their medication orders. LPA attempted to obtain the resident's most recent appraisal, however there was none available on record.

Deficiency was issue per Title 22, Division 6, Chapter 8, Article 8 and is cited on the LIC809D page. Exit interview was conducted and a copy of the appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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 01/24/2025 03:34 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 01/24/2025 at 03:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WHITTIER GLEN ASSISTED LIVING
FACILITY NUMBER: 198603162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
87457(c)

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(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
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Administrator is to ensure that appraisals for all residents are available at all times. Administrator is to create a plan explaining how the facility will ensure that appraisal are conducted, documented, and available at all times in the facility and submit this plan to the LPA by the POC due date.
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This regulation is not met as evidence by:
Based on record review, it was determined that there was no available pre-admission appraisal or recent appraisal available for C1, 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:David Sicairos
LICENSING EVALUATOR NAME:Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
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