198603485-7-29-2024-28-AS-CWOG-D7N26E-20240729170702

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603485
Report Date: 07/29/2024
Date Signed: 07/29/2024 05:09:46 PM

Document Has Been Signed on 07/29/2024 05:09 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 COTTAGE II		FACILITY NUMBER:	198603485
ADMINISTRATOR:	TRAZO-BOHANAN, VILMA		FACILITY TYPE:	740
ADDRESS:	16222 MARLINTON DR.		TELEPHONE:	(562) 315-9897
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90604
CAPACITY:	6	CENSUS: 3	DATE:	07/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	James Trazo-Administrator		TIME COMPLETED:	05:20 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 and Nurse Consultant Olive Divranos conducted the Unannounced required annual inspection. LPA arrived unannounced and met with caregiver Elizabeth Panyan and shortly after the Administrator James Trazo arrived and assisted with the visit. The purpose for the visit was explained. The facility is licensed range 60 and over, approved for 6 non-ambulatory and approved hospice waiver for 6. Currently, the facility has 3 hospice waiver residents and 0 home health residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan in place. All staff have the health screening and chest x ray result in file. 2. Operational Requirement: The current plan of operation is completed. A fire clearance approved for 6 NON-AMBULATORY. LPA currently has three residents in the facility and all 3 residents are non-ambulatory. LPA obtained the updated copy of facility Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place. 3. Physical Plant and Environmental Safety: The facility is a single story house and located in the residential neighborhood area. The facility includes: living room, dining area, kitchen/laundry area, TV room, three residents bedrooms and two bathrooms and attached garage. Each residents bedrooms have two beds, drawers, required furniture and beddings and sufficient lighting and closet space. The residents bathrooms are clean, sanitary and in a good working condition. The hot water temperature in both bathrooms were tested between 105 and 112.8 degrees F which is within the title 22 regulation. Each bathroom has the required grab bar and non-skid mat. All the cleaning supplies and chemicals are stored and locked in the cabinet next to the laundry area. LPA inspected the carbon monoxide detectors and it's mounted on the wall near the laundry area and it's working properly. Each residents rooms has a working smoke detectors. The passageway, walkway and patio are free of obstruction.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WHITTIER COTTAGE II	FACILITY NUMBER: 198603485
	VISIT DATE: 07/29/2024

NARRATIVE

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4. Staffing: The facility has sufficient staffing in the facility. All staff has the updated First Aid and CPR certificate.

5. Personnel Records-Training: All the staff in the facility are over 18 years old and fingerprint cleared. The administrator is Vilma Trazo Bohanan and her administrator certificate expired on 11/23/23 but currently it's pending in the CCL system and has the required training hours. LPA review two staff files and they have the required documents included employee application, required training hour and first aid certificate and CPR certificate.

6. Resident Right-Information: The facility has the required poster include Long Term Care Ombusman, Licensing Poster and Resident's Personal Right. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician.

7. Planned Activity: The facility has sufficient space to accommodate indoor and outdoor activity for residents.

8. Food Service: Currently there's no resident is on any modified diet that prescribed by the doctor. The facility has sufficient food supply for two days perishable and seven days non-perishable in the facility. All the food in the facility are stored properly. LPA did the kitchen tour and all the appliances are working properly. All the sharp knives and utensils are stored and locked in the kitchen drawer.

9. Incidental Medical and Dental: The facility would assist residents for medical and dental care appointments if needed. All the residents' medication are centrally stored in the cabinet in the TV room and LPA inspected all three (3) residents medication and they are updated and accurate and they have 30 days supply of medication.

10. Residents Record-Incident Reports: LPA inspected 3 resident files and they all have the required documents in file which include: Identification and Emergency Information, admission agreement, and TB test result, medical consent and medication record. LPA reviewed R1-R3 has the empty pre-admission appraisal and R1 does not have any updated physician report and needs and service plan.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and the facility has two appropriate shelter location. The last fire/disaster drill was conducted on 6/6/24. Records of resident Appraisal and Needs services plans are part of Emergency training.

12. Residents with Special Health Needs: Three (3) residents are receiving hospice services. No resident on Home Health. No resident in the facility is on any postural support. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. LPA observed bed rail in the facility and physician order is in file.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Administrator James Trazo A copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/29/2024 05:09 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WHITTIER COTTAGE II	FACILITY NUMBER: 198603485
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(5)

87705(5) Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA obserevd R1 does not have an updated Medical assessment and last one was dated in 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	The administrator will send the updated LIC602 to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 07/29/2024 05:09 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WHITTIER COTTAGE II	FACILITY NUMBER: 198603485
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed all residents's pre-admission appraisal form is empty which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	The administrator will ensure prior to accept a resident and has to perform a pre-admission appraisal and will send the plan to LPA for about future residents admission by POC due date.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA did not observe R1's needs and service plan ,which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/05/2024
	Plan of Correction
1 2 3 4	The administrator will send R1's needs and service plan to LPA by POC due date.

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	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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