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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603222
Report Date: 01/13/2023
Date Signed: 01/13/2023 04:21:50 PM


Document Has Been Signed on 01/13/2023 04:21 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:WHITTIER PLACE SENIOR LIVINGFACILITY NUMBER:
198603222
ADMINISTRATOR:WASHINGTON, MELANIEFACILITY TYPE:
740
ADDRESS:12315 BURGESS AVENUETELEPHONE:
(562) 777-1477
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY:125CENSUS: 52DATE:
01/13/2023
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Tierre Thornton TIME COMPLETED:
04:30 PM
NARRATIVE
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LPA Angelica Rea conducted an unannounced visit for the purpose of conducting a case management visit. On today's visit LPA met with Administrator, Tierre Thornton.

During annual visit conducted on 1/6/23, LPA observed that there were Resident #1 - Resident #3 were Covid positive. Administrator stated that report(s) for covid positive residents would be submitted on 1/6/23. However, Administrator has not reported covid positive residents up to this date. Facility will be cited accordingly.

Copy of report and appeal rights provided to Ms. Thornton.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
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 2


Document Has Been Signed on 01/13/2023 04:21 PM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: WHITTIER PLACE SENIOR LIVING
FACILITY NUMBER: 198603222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2023
Section Cited

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Administrator will submit Special Incident Report(s) for Residents #1 - #3 to Community Care Licensing by POC due date, and will submit proof that report has also been made to the Department of Public Health. Administrator will review Section 87211 and will send written statement stating that the section was read and is understood.
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This requirement is not met as evidenced by:

Administrator failed to report 3 covid positive resident(s) to Community Care Licensing as required, which poses a 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: Angelica ReaTELEPHONE: (323) 980-4929
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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