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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004192
Report Date: 11/13/2020
Date Signed: 11/17/2020 04:34:55 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2020 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200717105824
FACILITY NAME:WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306004192
ADMINISTRATOR:MELCHOR DE LEONFACILITY TYPE:
740
ADDRESS:200 WEST WHITTIER BLVD.TELEPHONE:
(562) 691-1200
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:196CENSUS: 97DATE:
11/13/2020
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator Carol LeeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility does not have adequate staffing to meet the needs of the residents.
Facility is not assisting resident with bathing
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Sean Haddad and Shobhana Frank contacted the facility via tele-visit due to COVID-19 precautionary measures to deliver findings for the investigation into the above identified complaint allegations. LPAs spoke with Administrator Carol Lee and explained the purpose of the telephone call.

The investigation into allegations that the Facility does not have adequate staffing to meet the needs of the residents and the Facility is not assisting resident with bathing revealed the following:

During the course of the investigation, LPAs interviewed witnesses, staff, and residents as well as obtained and reviewed Facility staff schedule, bathing schedule, and resident room cleaning schedule in effect during the period of 6/1/20 to 9/29/20. On 7/24/20, the Facility had a census of 102. The staff schedule indicates the following number of caregivers assigned to each floor: One (1) or two (2) in July, two (2) in August, and Two (2) in September. (Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2020 and conducted by Evaluator Sean Haddad
COMPLAINT CONTROL NUMBER: 22-AS-20200717105824

FACILITY NAME:WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306004192
ADMINISTRATOR:MELCHOR DE LEONFACILITY TYPE:
740
ADDRESS:200 WEST WHITTIER BLVD.TELEPHONE:
(562) 691-1200
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:196CENSUS: 97DATE:
11/13/2020
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator Carol LeeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Resident rooms are not being cleaned.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Sean Haddad and Shobhana Frank contacted the facility via tele-visit due to COVID-19 precautionary measures to deliver findings for the investigation into the above identified complaint allegations. LPAs spoke with Administrator Carol Lee and explained the purpose of the telephone call.

The investigation into allegations that Resident rooms are not being cleaned revealed the following:

During the course of the investigation, LPAs Haddad and Frank interviewed witnesses, staff, and residents and obtained and reviewed Facility housekeeping schedule in effect during the period of 6/1/20 to 9/29/20. Despite the staffing shortage confirmed during this time and a witness statement claiming certain resident rooms were not cleaned for a month, that was not corroborated by staff or residents interviewed. In addition, LPAs could not corroborate this allegation based on observations made during tele-visits conducted on 6/16/20 or 7/22/20. (Continued in 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20200717105824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306004192
VISIT DATE: 11/13/2020
NARRATIVE
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Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with Administrator via tele-visit a copy of the report along with appeal rights was sent via email and an electronic email read receipt confirms receiving of the report. Administrator agrees to review, agrees to send the signed report via email.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20200717105824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306004192
VISIT DATE: 11/13/2020
NARRATIVE
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However, LPAs interviewed Staff #1 (S1) who stated that in June 2020 and the surrounding months, a number of Facility staff were COVID positive and unable to work. In addition, Administrator De Leon prevented staff from entering Facility who were not positive, but who had second jobs at COVID positive facilities or had family members who worked at COVID positive facilities. Moreover, Staff #2 (S2) confirmed that during this time, staffing levels dropped drastically, sometimes to 50% of Facility’s current staffing level, meaning that at that time, three (3) Facility staff were expected to care for 60 assisted living residents and 40 memory care residents. The bathing schedule indicates Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), Resident #5 (R5), and Resident #6 (R6) were to be bathed by hospice bathing aides. However, S1 and S2 stated that during this time Administrator De Leon prevented hospice bathing aides from entering Facility, so they could not bathe residents according to the schedule. Moreover, Staff #3 (S3) disclosed that during this time, caregivers and other staff were preoccupied with providing in-room dining services for residents so they were not able to meet the needs of the residents and keep up with the resident bathing schedule. Finally, S2 confirmed the bathing schedule was not followed during this time.

During the course of the investigation, CCLD obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator via tele-visit a copy of the report along with appeal rights was sent via email and an electronic email read receipt confirms receiving of the report. Administrator agrees to review, agrees to send the signed report via email.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20200717105824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306004192
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2020
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Based on LPAs’ interviews and review of staffing records,
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Licensee states they will have adequate staff working at all times and prepare and submit to LPA contingency plans, including plans for using staffing agencies and expediting hiring of permanent staff, to prevent future staffing shortages.
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in June 2020 and the surrounding months staffing levels dropped drastically due to COVID-19 so the staff was overextended and not able to meet the needs of the residents. This poses an immediate health, safety, and/or personal rights risk to persons 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20200717105824
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306004192
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2020
Section Cited
CCR
87464(f)(4)
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Basic services shall ... include: (4) Personal assistance and care as needed …, with ... bathing… This requirement was not met as evidenced by: Based on LPAs’ interviews andreview of records, in June 2020 and the surrounding months, bathing schedule could not have been followed because Facility
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Licensee states they will update their bathing schedule and keep a log of showers/baths provided to and/or refused by residents so bathing schedule can be readily confirmed in the future.
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lost staff, current staff were overextended, and outside bathing aids were not allowed in. Facility staff confirmed bathing schedule not followed. This poses a potential health, safety, and/or personal rights risk to persons 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: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 355-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 6