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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004192
Report Date: 08/29/2024
Date Signed: 08/29/2024 10:30:10 AM


Document Has Been Signed on 08/29/2024 10:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
306004192
ADMINISTRATOR:STEVE SHENFACILITY TYPE:
740
ADDRESS:200 WEST WHITTIER BLVD.TELEPHONE:
(562) 691-1200
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:196CENSUS: 127DATE:
08/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Allen NishikawaTIME COMPLETED:
10:45 AM
NARRATIVE
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This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20201221092131. LPA met with Administrator (AD) Allen Nishikawa and explained the reason for today’s inspection.

During the course of the investigation, LPA inspected the facility, interviewed AD, Chief Operating Officer (COO) Faye Shen, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Resident File, and Medication Administration Records (MAR) for multiple residents.
When interviewed, R1 stated that they had previously received the wrong medications which caused a severe reaction, so they double-check the medications they receive from the medication technician. Regarding the alleged past medication error, R1 did not specify if it occurred at this facility or another location. LPA reviewed R1’s Resident File and interviewed the staff in charge of medications and did not obtain information corroborating a medication error. LPA reviewed the MAR for R1 and noted dozens of instances of medications not being signed off as being given to R1 with no documented explanation, although LPA obtained no evidence of R1 suffering a severe reaction. The MAR for four other residents also showed similar blanks where the medications were not signed off, but the pills were no longer in the bubble packs. Per the staff in charge of medications, the reason the doses were not signed off by the medication technician is because the medication technician forgot or did not have time to sign off on the dose and this does not indicate that the medications were not given. However, the doses were still not properly documented as required to ensure residents were receiving their medications as required.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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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Document Has Been Signed on 08/29/2024 10:30 AM - 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
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: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee stated that they will create a procedure for ensuring the MAR is completed properly and will train medication technicians on the procedure and submit proof to LPA by POC due date.
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Based on documents and interviews, the licensee did not ensure the medications for 5 out of 5 residents were documented on the MAR as being given as prescribed, which poses a potential health 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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