198603222-9-8-2023-28-AS-RORN-CVUP86-20230920110501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603222
Report Date: 09/08/2023
Date Signed: 09/08/2023 01:24:25 PM

Unsubstantiated

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
04/11/2023 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230411160700

FACILITY NAME:	WHITTIER PLACE SENIOR LIVING		FACILITY NUMBER:	198603222
ADMINISTRATOR:	WASHINGTON, MELANIE		FACILITY TYPE:	740
ADDRESS:	12315 BURGESS AVENUE		TELEPHONE:	(562) 777-1477
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90604
CAPACITY:	125	CENSUS: 66	DATE:	09/08/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Joshua Castillo, Executive Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident developed multiple pressure injuries due to neglect by staff resulting in death
Facility staff did not seek timely medical attention for resident's pressure
injuries
Facility staff hit resident resulting in bruising
Facility staff did not provide resident with linens in good condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit to deliver the final results of the investigation. LPA met with Administrator, Joshua Castillo who assisted with today's visit.

Regarding the allegation that : Resident developed multiple pressure injuries due to neglect by staff resulting in death. The investigation was conducted by the department and consisted of review of resident #1's file, including home health records, interviews with facility staff, and medical personnel who provided care to resident #1. Investigation revealed that resident #1 lived at the facility from 2/25/23 to 3/22/23. The investigation revealed that there was contradicting information regarding the stage of the resident #1 wound(s). Resident #1's home health records indicate that resident #1 had no pressure injuries when discharged from home health on 3/22/23. Health insurance records indicate that resident #1 had a stage 3 wound the day before transferring out of the facility. However,interviews and documents reviewed indicate that resident #1 was observed to have a stage 2 wound while living at the facility, but was receiving regular wound care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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-20230411160700

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 PLACE SENIOR LIVING	FACILITY NUMBER: 198603222
	VISIT DATE: 09/08/2023

NARRATIVE

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Regarding the allegation that: Facility staff did not seek timely medical attention for resident's pressure
injuries. The investigation was conducted by the department and consisted of review of resident #1's file, including home health records, interviews with facility staff, and medical personnel who provided care to resident #1. The investigation revealed that home health records listed that resident #1 had no pressure injuries when discharged from home health upon the date of discharge from the facility. Health insurance medical records contradict this information and list that resident #1 had a stage 3 wound the day before transferring out of the facility. Health insurance confirmed that resident #1 was discovered with stage 3 wound, resident #1's daughter was informed resident #1 must be transferred out for higher level of care , and hospice care was scheduled for the following day. Interviews and documentation list that resident #1 was observed with a stage 2 wound while at the facility, but was receiving regular treatment/ wound care. On the day resident #1 was transferred out of the facility, transferring administrator advised that LVN assessment stated that resident #1 wounds were a stage 2. There was insufficient evidence that the facility did not seek timely medical attention.

Regarding the allegation that: Facility staff hit resident #1 resulting in bruising, the investigation consisted of review of resident #1's file, review of medical records, and interviews with Administrator, and Staff #1 - Staff #3. 4 out of 4 staff interviewed stated that they have not observed any residents being hit by staff. Review of resident #1's flie, indicates that resident #1 was taking medication that can cause bruising.

Regarding the allegation that : Facility staff did not provide resident with linens in good condition. The investigation consisted of tour of facility, including resident rooms, and interviews with Administrator and staff #1 - staff #3. LPA did not observe linens in poor condition during initial and subsequent tours of resident room(s). Administrator and staff interviewed, stated that resident family members bring their own linens to the facility, and they are laundered by facility staff.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted with Mr. Castillo, and copy of report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC9099 (FAS) - (06/04)

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