306004192-2-27-2024-22-AS-LMOA-D2X4ZS-20240229183314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004192
Report Date: 02/27/2024
Date Signed: 02/27/2024 03:26:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
07/07/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230707101643

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: 115	DATE:	02/27/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Faye Shen- Chief Operating Officer		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Resident was injured by a resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of continuing the investigation and delivering the findings into the above allegation. LPA met with Chief Operating Officer (COO) Faye Shen and General Manager (GM) Allen Nishikawa and explained the reason for the visit.

On July 13, 2023, LPA initiated the complaint investigation. A subsequent visit was conducted on October 19, 2023. During the course of the investigation, LPA interviewed four residents and eight staff and obtained the following documentation: resident/staff rosters, June 2023 staff schedule, Incident Report dated July 6, 2023, Communication Logs from June 6, 2023, to June 29, 2023, floor plan, and four resident records which includes the face sheet and physician’s report. During today’s visit, LPA reviewed the records received. The investigation revealed the following:

It is alleged that a resident was injured by a resident in care. [Continued on LIC9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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-20230707101643

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 306004192
	VISIT DATE: 02/27/2024

NARRATIVE

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On June 24, 2023, Resident #1 (R1) and Resident #2 (R2) were involved in an altercation as documented on the Incident Report dated July 7, 2023. It was also noted that R2 pushed R1 off their wheelchair. Per review of the incident report, R1 was assessed, and no injuries were sustained. Interviews revealed that four out of the four residents and seven out of the seven staff were aware of the altercation between R1 and R2. However, only one out of the four residents and one out of the seven staff indicated that R1 suffered bruising related to the fall.

Therefore, based on the interviews and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Resident was injured by a resident in care is deemed UNSUBSTANTIATED.

An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report including the LIC9099C, and the LIC811 were provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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