306004192-10-15-2024-22-AS-LMOA-DAFTUQ-20241027150242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004192
Report Date: 10/15/2024
Date Signed: 10/15/2024 10:35:07 AM

Substantiated

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
10/09/2024 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241009123331

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:	10/15/2024
		UNANNOUNCED	TIME BEGAN:	07:00 AM
MET WITH:	Faye Shen- Chief Operating Officer		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff did not ensure hallways are free from obstruction.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Jessica Cho and William Vanega arrived at the facility unannounced for the purpose of conducting the 10-day complaint investigation into the above allegation. LPAs were greeted and granted entry by Receptionist Gerardo Reyes and Activity/Housekeeping Supervisor Clara Ramirez after explaining the purpose of the visit. During the course of the investigation, LPAs inspected the indoor passageways and conducted four staff interviews and two out of the six resident interviews. LPAs did not take statements of the remaining four residents as they were either occupied or refused the interview. LPAs obtained pertinent documentation which includes the Resident/Staff Roster, Face Sheets, Physician's Report, an Admission Agreement, Care Note, and Pet Addendum.

The investigation revealed the following: It is alleged that the facility did not ensure hallways are free from obstruction. Based on LPAs' observations of the hallways of the the three levels approximately 8:25am, LPAs observed the indoor passageways were clear of tripping hazards. LPAs observed the black dog named Karma present in the resident's room at the time of inspection.

Substantiated

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: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

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-20241009123331

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/22/2024 Section Cited CCR 87307(d)(6)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that the facility will post signs requiring all pets to be leashed or in a carrier at all times and will submit proof of the signs and an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the black dog became a tripping harzard for R1 causing R1 to trip and fall on 10/06/24 which poses a potential Safety Risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20241009123331

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: 10/15/2024

NARRATIVE

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However, based on the interviews with one out of the two residents, one witness resident confirmed Resident #1 (R1) falling on October 6, 2024 as a result of a black dog running in the hallway of the 1st floor. The second resident stated that they did not observe or have knowledge of the fall. Additionally, four out of the four staff confirmed R1 falling. Based on the review of the Care Note dated October 6, 2024, R1 did in fact sustain a fall because of the dog.

Therefore, based on LPA's observations, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility did not ensure hallways are free from obstruction is deemed SUBSTANTIATED. A deficiency is being cited as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations is being cited on the attached LIC 9099D.

An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report including the appeal rights 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: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC9099 (FAS) - (06/04)

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