306004192-9-10-2024-22-AS-AORZ-DADV5Y-20241025160843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004192
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:36:50 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
07/24/2024 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20240724140359

FACILITY NAME:	WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	306004192
ADMINISTRATOR:	STEVE SHEN		FACILITY TYPE:	740
ADDRESS:	200 WEST WHITTIER BLVD.		TELEPHONE:	(562) 691-1200
CITY:	LA HABRA	STATE: CA	ZIP CODE:	90631
CAPACITY:	196	CENSUS: 127	DATE:	09/10/2024
		UNANNOUNCED	TIME BEGAN:	02:01 PM
MET WITH:	Faye Shen - Chief Operating Officer		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not provide adequate care and supervision to a resident
Staff do not have adequate record keeping for a resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Receptionist. LPA met with Faye Shen, Chief Operating Officer and explained the nature of the inspection.

The department received a complaint on 7/24/2024 stating staff do not provide adequate care and supervision to a resident and that staff do not have adequate record keeping for a resident. During the investigation, the department interviewed the Chief Operating Officer (COO), staff and residents in care.

(continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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 2

Control Number 22-AS-20240724140359

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 306004192
	VISIT DATE: 09/10/2024

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
26
27
28
29
30
31
32

(continued from LIC9099)

On 8/2/2024 LPA conducted a visit to the facility. LPA obtained copies of the staff schedule for the month of August 2024, staff contact information and resident census for 8/2/2024. LPA toured the facility and interviewed staff and residents in care.

In regards to the allegation of staff do not provide adequate care and supervision to a resident, LPA conducted interviews with five residents who indicated being able to recall R1 when they resided at the facility. Of the five residents interviewed, four stated they do not believe the staff neglected R1 based on their observations. LPA conducted interviews with COO and three staff (S1, S2, S3). Of the four staff interviewed, four stated they do not believe the staff neglected R1.

In regards to the allegation of staff do not have adequate record keeping for a resident, LPA returned to the facility on 8/15/2024. LPA reviewed R1's file. LPA obtained copies of all of the documentation in the resident's (R1's) file. These files include: copy of state identification card, copy of health insurance card, copy of benefits identification card, admission record from previous facility, physician's report, admission agreement dated 5/17/2024, Assisted Living Waiver Informing Notice, Reassessment checklist, Medi-Cal Eligibility printout, signed Service Plan Agreement, completed assessment tool dated 3/14/2024, Individual Service Plan, physician's orders and medication administration record. LPA conducted interviews with COO and Staff (S1, S2, S3). COO stated no documents were removed from or added to R1's records after they moved out of the facility. S1, S2, S3 made no disclosures regarding the allegation. Based on Title 22 Regulations, R1's file contains all the required documentation. Based on interviews conducted, LPA was unable to determine if R1's file did or did not have the same documentation in it while R1 resided at the facility.

Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation(s). Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and this report was reviewed with Faye Shen, Chief Operating Officer (COO). A copy of this LIC-9099 was provided to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2