198603162-3-23-2022-28-AS-WSHO-CCZ3DU-20220329181006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 03/23/2022
Date Signed: 03/23/2022 05:26:06 PM

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
03/16/2022 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20220316094043

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	ATEAIAN, KIMIA		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 68	DATE:	03/23/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director Sophia Chan		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff not administering medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted a complaint inspection on the above allegation. LPA arrived unannounced and met with the Executive Director Sophia Chan and explained the purpose of the inspection.
The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA reviewed Resident #1 (R1) file and obtained copies of Face Sheet, Physician's Report, and Resident Appraisal. LPA interviewed Executive Director, Staff #1 (S1) and Resident 2 (R2). LPA also reviewed a random sample of residents medications during today's visit and observed medications to be not documented properly and given as prescribed. LPA was unable to interview R1 because R1 was not at the facility during the visit.

Continue 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220316094043

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: WHITTIER GLEN ASSISTED LIVING	FACILITY NUMBER: 198603162
	VISIT DATE: 03/23/2022

NARRATIVE

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The investigation revealed the following: It was alleged the facility was not providing residents medication as prescribed.

Interviewed staff indicated residents are provided with medication as prescribed. R2 stated that staff not providing medication as prescribed.

Upon reviewing R1's Medication Administration Log (MAR log), LPA observed that the 325 mg, 500 mg and 650 mg Acetaminophen were ordered by doctor on 12/31/21 and not given to R1 as prescribed. 650 mg Acetaminophen was not seen at the facility at the time of visit. The MAR log was signed off that Rosuvastatin Calcium 10 mg administered as prescribed but the medication was still packaged and not dispensed for 3/6/22. Upon reviewing R2's MAR LPA observed that Loratadine 10mg signed off for 03/14/22 and administrated as prescribed, but the medication was still packaged for 03/14/22.

Based on LPA interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Deficiencies cited under California Code of Regulations Title 22. See 9099D.

Exit interview conducted and copy of the report with appeal rights was provided to Executive Director.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220316094043

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: WHITTIER GLEN ASSISTED LIVING	FACILITY NUMBER: 198603162
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/24/2022 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly ...provided all of the following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	The Licensee shall conduct staff training on medication documentation to ensure that they are providing medication to residents as prescribed.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Facility failed to provide Acetaminophen 325 mg, 500mg and 650 mg R1 as prescribed. Facility failed to provide Loratadine 10mg R2 as prescribed. This poses an immediate Health and Safety risk to clients in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC9099 (FAS) - (06/04)

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