306004192-3-23-2023-22-AS-SSAS-CW4Q9T-20230928115849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004192
Report Date: 03/23/2023
Date Signed: 03/23/2023 11:42:11 AM

Unfounded

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
10/21/2022 and conducted by Evaluator Jerome Haley

COMPLAINT CONTROL NUMBER: 22-AS-20221021170228

FACILITY NAME:	WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	306004192
ADMINISTRATOR:	CHIN SHUN LEE LIAU		FACILITY TYPE:	740
ADDRESS:	200 WEST WHITTIER BLVD.		TELEPHONE:	(562) 691-1200
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	196	CENSUS: 94	DATE:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	11:21 AM
MET WITH:	Fae Chin		TIME COMPLETED:	11:31 AM

ALLEGATION(S):

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Staff did not file required reports regarding resident injuries

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to deliver the findings on the complaint allegation above.
During the investigation, LPA Haley made two unannounced visits to the facility to gather additional information on the complaint allegations. The initial visit was made October 28, 2022, and a follow up visit was made February 8, 2023. During the unannounced visits to the facility LPA Haley interview residents and staff. Furthermore, LPA Haley conducted telephone interviews to obtain additional details on the complaint allegations.

Regarding the allegation, Staff did not file required reports regarding resident injuries

During the investigation, LPA Haley interviewed Facility COO Fae Chin who provided LPA Haley a copy of the incident report, and Facility Incident Log that was written regarding the incident and faxed to the Orange County Adult and Senior Care Program Regional Office October 10, 2022.
Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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 22-AS-20221021170228

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: 03/23/2023

NARRATIVE

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COO Chin also provided a fax receipt dated October 10, 2022. Furthermore, LPA Haley checked the incident reports received by the Orange County Adult and Senior Care Program Regional Office and the incident report regarding the incident was received and date stamped October 11, 2022.

Based on the information gathered during the investigation, observation, and review of all documents obtained, the following allegation: Staff did not file required reports regarding resident injuries, is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

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