Whittier Cottage

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) James Trazo and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 3:00PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 7-bedroom, 3-bathroom, two-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 2 staff and 6 residents present at the facility in addition to AD. Resident Bedrooms: the 5 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 2 staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 109 and 110 degrees F in the 2 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage, after corrections. Medication cabinet: relocated to a lockable closet, after corrections. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 1:45PM, LPA reviewed 6 resident files and 4 staff files, interviewed 2 residents and 2 staff, and inspected medications for 6 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on observation, the facility's fire extinguisher was last serviced on June 10, 2025; based on observation, the locks to the toxin drawer under the sink and the medication cabinet in the kitchen were broken, leaving toxins and medications accessible to residents not assessed as being able to safely handle these items; based on documents, R3's physician's report does not have a TB test result; based on documents, the physician's reports for R1, R2, R4, and R5 are on the old form and do not contain required information, including behavioral expressions; based on documents, the appraisals for R1, R2, and R4 are more than a year old; and based on observation and interview, R5, who is not on hospice, has a full bedrail on their bed which was not locked in place and R5 stated it is not used and they are able to get in and out of bed themselves and walk. 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.the state’s words, verbatim · CDSS document, Jun 25, 2026

Type of visit: Case Management - Incident

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on December 15, 2025, regarding Resident #1 (R1). LPA met with Administrator (AD) James Trazo and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility, interviewed AD and witnesses, and requested and reviewed copies of the resident roster, staff roster, and resident files. Per the incident report received in the OCRO on December 15, 2025, on December 13, 2025, R1 was taken via medical transport to a routine doctor’s appointment at 7:00AM, refused to return to the facility after the appointment was over, is now missing, and local law enforcement and R1’s family were notified. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA reviewed R1’s Physician’s Report dated November 21, 2025, which indicates R1 does not have Dementia or Mild Cognitive Impairment, R1 is not able to leave the facility unassisted because R1 is “bedbound”, R1 is bedridden, and R1’s ambulatory status is based only on physical condition. Per a letter from R1’s medical provider, R1 was placed at the facility on November 21, 2025. LPA interviewed AD who stated that R1 had always previously gone to these daily doctor’s appointments with their family as their family transported them there, this was the first time R1 went by themselves via medical transport without their family, and after the appointment was over R1 refused to return to the facility with the medical transport. LPA reviewed a communication from the medical transport confirming that R1 refused to return to the facility and had signed documentation confirming their refusal. Per AD, staff at the doctor’s office observed R1 leaving with someone, R1’s family and local law enforcement were notified immediately, and law enforcement documented the case as a voluntary missing person. AD stated that staff at the doctor’s office noted that R1 did not want to reside at the facility and AD believes that, when R1’s family did not accompany them during this appointment, R1 took the opportunity to not return to the facility. Per AD, R1’s family reported that a family friend saw R1 after they went missing, but for unknown reasons R1 was not returned to the facility, and R1’s family also reported that a police officer had made contact with R1, R1 is doing well, and R1’s family has a general idea of where R1 is and is planning to try to convince R1 to return to the facility or go to the hospital. LPA made contact with R1’s family, but was unable to obtain information from R1’s family. LPA interviewed the La Habra Police Detective overseeing R1’s case who stated that R1 had lied and said they were being picked up from the doctor’s appointment by their family, but had actually coordinated with someone who met them at the doctor’s office to wheel them out in their wheelchair, R1 was found in Whittier and is living on the streets by choice, R1 does not want to return to the facility, R1 is able to make their own decisions and has no cognitive issues or court orders that would allow law enforcement to further intervene, and the case has been closed. LPA interviewed staff at R1’s doctor’s office who confirmed the details of the incident and stated that R1 actually returned to the office on December 16, 2025, but has not returned since. Per AD, the facility did not purposefully send R1 to the doctor’s appointment without supervision and believed R1’s family would meet them at the appointment. However, it was still the facility’s responsible to ensure R1 was supervised at all times, as R1 is unable to leave the facility unassisted, and in this case R1 was unsupervised while on the medical transport, as the communication from the medical transport indicates the transport personnel do not have a duty to supervise passengers and would allow passengers to exit any time during transit, and R1 was unsupervised at the doctor’s office. In addition, this was the first day R1 was taking medical transport to their daily doctor’s appointments, as opposed to being transported by their family, and the facility needed to confirm with R1’s family that they would meet R1 at the appointment and it appears there may have been some miscommunication. Based on the information obtained, R1 is no longer a resident of the facility after refusing to return and choosing to make alternative living arrangements as R1 had the capacity to make those decisions. AD stated that R1’s placement agency terminated R1’s placement at the facility the day R1 left. LPA noted R1’s file was not present at the facility. Per AD, R1 took the paperwork with them to complete it with their family and that is why it is not present. Based on this information, the facility did not maintain a file for R1 as it is not present at the facility and it was not complete.Based on the information obtained 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.the state’s words, verbatim · CDSS document, Dec 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 23, 2025

87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision. This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not ensure R1 received care and supervision to meet their needs when they were unsupervised at their doctor’s appointment and decided not to return to the facility, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 22, 2025

Plan of correction: Licensee stated they will retrain staff on residents’ ability to leave the facility unassisted and will continue to follow up with R1’s status and provide updates to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Dec 29, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility … This requirement was not met as evidenced by: Based on admission and documents, the licensee did not have a complete resident file for R1, which poses potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 22, 2025

Plan of correction: Licensee stated they will create a protocol for completing resident files prior to admission and submit proof to LPA by POC due date.

Type of visit: Case Management - Incident

On December 16, 2025, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on an incident report received from the facility. LPA Kim was greeted and granted entry by staff. LPA Kim spoke over the phone with Administrator (ADMIN) Vilma Bohanan-Trazo and explained the purpose do the visit. ADMIN Trazo stated they could not make today's visit and Staff James Trazo would sign on behalf of the facility. LPA Kim conducted a health and safety check with Staff Trazo. There were no health and safety concerns at the time of the visit. LPA Kim reviewed and obtained the staff roster, the resident roster, and requested the following records of R1: letter of agreement, face sheet, pre-appraisal, incident reports, and other pertinent records. An exit interview was conducted, and a copy of this report and LIC811 was provided to Staff James Trazo.the state’s words, verbatim · CDSS document, Dec 16, 2025

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Vilma Bohanan-Trazo and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 1:30PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 7-bedroom, 3-bathroom, two-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 3 staff and 5 residents present at the facility in addition to AD. Resident Bedrooms: the 5 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 2 staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110 and 111 degrees F in the 2 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 2:30PM, LPA reviewed 5 resident files and 3 staff files, interviewed 2 residents and 2 staff, and inspected medications for 5 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on documents, the licensee did not ensure Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) had health screenings all of whom have been working at the facility for more than 7 days; based on documents, the licensee did not ensure S2 had the 20-hour annual training for 2025; and based on documents and interviews, the licensee did not ensure S2 who assists residents with medications has documented medication training. 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.the state’s words, verbatim · CDSS document, Jul 9, 2025

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Vilma Bohanan-Trazo and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 1:00PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 7-bedroom, 3-bathroom, two-story house with attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA and AD observed 1 staff and 5 residents present at the facility. Resident Bedrooms: the 5 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 2 staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 113.5 degrees F in the common resident bathroom and 113 degrees in the private resident bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage and kitchen. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 2:00PM, LPA reviewed 5 resident files and 2 staff files, interviewed 2 residents and 1 staff, and inspected medications for 5 residents. Facility does not handle resident money. CONTINUED During the inspection, LPA and AD observed the following: LPA determined using the Licensing Information System that staff Sheryl Borja is not background cleared and has been working at the facility since January 1, 2024 per their staff file; based on observation, the facility's PUB475 is letter-sized and not 20"x26"; based on documents, the facility has not been completing Medication Administration Records (MAR) for 2 out of 5 residents; and based on observation, the facility has two stories with staff living upstairs but does not have an evacuation chair 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. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 8, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.