Whitten Heights Assisted Living And Memory Care

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) UnsubstantiatedRead the full finding— CDSS inspection report, September 10, 2024 · control 22-AS-20240724140359

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Allen Nishikawa and explained the reason for today’s inspection. The investigation into the allegation that a resident's incontinent needs are not being met revealed the following: 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 Appraisal dated June 22, 2018, R1’s Physician’s Report dated September 9, 2019, R1’s Physician’s Report dated October 8, 2019, and R1’s Admission Agreement dated June 22, 2018. CONTINUED UnfoundedRead the full finding— CDSS inspection report, August 29, 2024 · control 22-AS-20201221092131

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate n investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and resident. Regarding the allegations that staff turns off lights without consent and staff enters room without knocking on the door, the investigation revealed the following: Resident 1's (R1) room has signage posted on the door requesting staff to ring doorbell which has been installed. Posted signage states "Do not enter" without the resident's approval and following certain steps. Three out of three staff interviewed state ringing the doorbell before entering the room but indicate the resident does not always hear the doorbell. Resident indicates no staff should ever enter without the resident's approval. Staff 1 (S1) states entering the resident's room with approRead the full finding— CDSS inspection report, July 10, 2024 · control 22-AS-20240702095631

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Chief Operating Officer (COO) Faye Shen, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that the licensee failed to eradicate insect infestation revealed the following: During the course of the investigation, LPA inspected the facility, interviewed COO and residents, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s recent pest control invoices. CONTINUED UnsubstantiatedRead the full finding— CDSS inspection report, July 2, 2024 · control 22-AS-20240628153302

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with staff Kate Bernal, discussed the purpose of the inspection, and explained the allegation. Administrator (AD) Allen Nishikawa was not present during the inspection. The investigation into the allegation that staff handled resident in a rough manner revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, an Unusual Incident Report received May 17, 2024, Resident #1’s (R1) Physician’s Report dated November 2, 2023, R1’s Monthly Case Manager Visit Summary dated April 18, 2024, and R1’s Assisted Living Waiver Assessment dated November 22, 2023. UnsubstantiatedRead the full finding— CDSS inspection report, June 24, 2024 · control 22-AS-20240520140910

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as extermination records. Regarding the allegation that staff are not properly addressing pest infestation in facility, the investigation revealed the following: Facility staff indicate spraying resident rooms once advised of pests infestation and obtaining outside extermination. Rooms 135R, 105R and 230 were exterminated by Outstanding Pest Solutions on 06/10/2024. Facility indicates rooms 137L, 121, and 210 refused extermination. Two out of three residents of noted rooms deny refusing extermination. During the visit, LPA observed ants in room 137L and cockroaches on bed and table in room 210.Read the full finding— CDSS inspection report, June 18, 2024 · control 22-AS-20240617103710

Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit to the facility to complete additional interviews and deliver the findings on the complaint allegations made January 18, 2024. LPA Haley was greeted by staff and explained the reason for the visit. The complaint investigation consisted of interviews with facility staff, residents, a witness, document review, and observations. A total of 9 individuals were interviewed during the investigation and observations were made by LPA Haley during both visits to the facility. Regarding the complaint allegation: Residents smoke in the facility During the investigation, 4 of 5 staff members confirmed residents smoke in their room or have smelled smoke inside the facility. Staff 1 (S1) and Staff 2 (2) both acknowledged Resident 1 (R1) has a history of smoking inside R1's room. S1 and S2 both acknowledged they try to monitor the resident and make sure R1 goes to the designated smoking area. Continued on LIC9099C SubstanRead the full finding— CDSS inspection report, April 12, 2024 · control 22-AS-20240118101539

Regarding the complaint allegation: Staff drink alcohol in the facility During the investigation 8 of 9 individuals interviewed either denied or were unable to support the complaint allegation above. Staff 1 (S1) denied the complaint allegation and stated staff are not allowed to consume alcohol on their shift or work while intoxicated. Resident's are allowed to drink alcohol, as it's their personal right, as long as they drink responsibly and are not intoxicated. Staff 2 (S2) denied drinking while on duty and denied ever being intoxicated while on duty. Regarding the complaint allegation: Facility room is malodorous. During the investigation 5 of 5 staff denied the allegation above. Staff 5 (S5) stated some rooms have an odor because they have pets, but they clean up and after the room is clean the odor is not that strong. Continued on LIC9099C UnfoundedRead the full finding— CDSS inspection report, April 12, 2024 · control 22-AS-20240118101539

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Chief Operations Officer (COO) Faye Shen and explained the reason for today’s inspection. The investigation into the allegation that staff did not ensure hot water heater works properly revealed the following: During the course of the investigation, LPA inspected the facility, interviewed Administrator (AD) Allen Nishikawa, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, and a water shut-off notice dated April 5, 2024. Regarding the allegation that the staff did not ensure hot water heater works properly: it was alleged that the facility’s hot water goes out regularly, the longest outage lasted three days, and the most recent outage was during the week of March 25, 2024. UnsubstantiatedRead the full finding— CDSS inspection report, April 9, 2024 · control 22-AS-20240402152116

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by Chief Operating Officer- Faye Shen. It was alleged that facility did not ensure that resident's personal rights were respected. 4 out of the 5 resident interviews conducted did not corroborate with the allegation by stating that staff are respectful. 1 out of the 5 resident interviews stated that resident 1 (R1) does not like when staff enter their room, and added that only certain staff are allowed in their room due to personal preference. 3 out of the 3 staff interviews conducted did not corroborate with the allegation by stating that upon hire, staff are required to complete training regarding personal rights. LPA De Perio conducted a record review and observed that 3 out of the 3 staff had completed training regarding personal rights. It was alleged that facility staff are not properly trainedRead the full finding— CDSS inspection report, March 19, 2024 · control 22-AS-20240102113340

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Allen Nishikawa and explained the reason for today’s inspection. The investigation into the allegation that the facility did not provide adequate notice of rate change to residents and/or POA/responsible party revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, and a rent increase notice dated 02/26/24. Regarding the allegation that the facility did not provide adequate notice of rate change to residents and/or POA/responsible party: it was alleged that the facility did not provide proper notice of a rate change to residents. LPA requested and reviewed a rent increase notice dated 02/26/24 which indicates a rate increase will be effective on 03/31/24. SubstantiateRead the full finding— CDSS inspection report, March 12, 2024 · control 22-AS-20240306120233

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] UnsubstantiatedRead the full finding— CDSS inspection report, February 27, 2024 · control 22-AS-20230707101643

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by Chief Operating Officer - Faye Shen. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that the facility is not maintaining a comfortable temperature in the dining room and residents are too cold. During the tour of the physical plant of the facility, LPA observed that the temperature at the entrance of the dining room was observed to be at 76 degrees Fahrenheit, and the temperature in the central part of the dining room was measured to be at 75.0 degrees Fahrenheit. UnsubstantiatedRead the full finding— CDSS inspection report, January 18, 2024 · control 22-AS-20240111151910

On this Day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry by Steve Shen, Administrator and explained the reason for the visit. The Department received a complaint on 12/08/2023 and the initial 10-day visit on 12/15/2023. During the visit LPA Mendivil interviewed staff and residents. LPA Mendivil obtained copies of physician reports, admission agreement and appraisal. Regarding the allegations staff do not assist resident with medication management and resident did not receive medication as prescribed, the investigation revealed the following: Per review of Resident 1 (R1) physician report dated 04/26/2023 it is reported that R1 is able to administer their own medications and R1 is able to administer their PRN medications.Based on an interview with Chief Operating Officer Faye Shen, R1 is independent and does not want assistance from the Med-Techs for medication management. UnfoundedRead the full finding— CDSS inspection report, December 29, 2023 · control 22-AS-20231208160644

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for and to deliver the findings. LPA De Perio explained the purpose of today's visit, and was greeted by chief operating officer (S1) Faye Shen. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that facility did not seek medical attention. LPA conducted a total of 6 resident interviews who did not corroborate with the allegation by stating that the facility does contact 911 when needed or upon request. A total of 3 staff interviews were conducted, including the resident's (R1) nurse from an outside agency, of which all 3 interviews also did not corroborate with the allegation. UnsubstantiatedRead the full finding— CDSS inspection report, September 26, 2023 · control 22-AS-20230922124616

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with General Manager (GM) Allen Nishikawa, discussed the purpose of the inspection, and explained the allegation. The allegations that staff locked residents in their rooms and staff tied up residents were investigated by the Department and consisted of inspections, interviews conducted with the facility staff, Administrator, witnesses, and residents, as well as documentation review, and revealed the following: Staff admitted to restraining residents while they were in their wheelchairs with a Posey Gait belt. One of the Posey Gait belts was confiscated and placed into IB evidence. SubstantiatedRead the full finding— CDSS inspection report, July 28, 2023 · control 22-AS-20200917140130

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Medication Technician Angie Rentutar and Administrator Carol Lee arrived during the visit. During the course of the investigation, LPA interviewed staff as well as reviewed and obtained pertinent documentation such as Resident 1's file (R1). Regarding the allegation that facility staff did not provide complete records to resident's responsible party, the investigation revealed the following: Facility received a request for medical records from Tonon Attorney Service via Valentine Law Group on 11/18/2022. Facility provided partial records including physician reports and medication orders on 02/13/2023. Facility did not provide any other medical or facility records as requested. The preponderance of evidence standard has been met, therefore the above allegRead the full finding— CDSS inspection report, March 23, 2023 · control 22-AS-20230317120537

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to deliver the findings on the complaint allegation above. During the investigation, LPA Haley made two unannounced visits to the facility to gather additional information on the complaint allegations. The initial visit was made October 28, 2022, and a follow up visit was made February 8, 2023. During the unannounced visits to the facility LPA Haley interview residents and staff. Furthermore, LPA Haley conducted telephone interviews to obtain additional details on the complaint allegations. Regarding the allegation, Staff did not file required reports regarding resident injuries During the investigation, LPA Haley interviewed Facility COO Fae Chin who provided LPA Haley a copy of the incident report, and Facility Incident Log that was written regarding the incident and faxed to the Orange County Adult and Senior Care Program Regional Office October 10, 2022. Continued on LIC9099C UnfoundedRead the full finding— CDSS inspection report, March 23, 2023 · control 22-AS-20221021170228

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to deliver the findings on the complaint allegation above. During the investigation, LPA Haley made two unannounced visits to the facility to gather additional information on the complaint allegations. The initial visit was made October 28, 2022, and a follow up visit was made February 8, 2023. During the unannounced visits to the facility LPA Haley interview residents and staff. Furthermore, LPA Haley conducted telephone interviews to obtain additional details on the complaint allegations. Regarding the allegation, Staff are not providing a safe environment for residents in care During the investigation, LPA Haley interviewed 10 residents, 6 staff members, and facility COO Fae Chin. None of the individuals interviewed could confirm this allegation to be true. UnsubstantiatedRead the full finding— CDSS inspection report, March 23, 2023 · control 22-AS-20221021170228

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Carol Lee, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that Staff changed resident's diaper without permission revealed the following: During the course of the investigation, LPA interviewed AD, 2 staff, and 2 residents, and requested and reviewed copies of the resident roster, staff roster, and resident files. It was reported that staff changed Resident #1’s (R1) diaper without permission. Per AD, R1 moved out of the facility on 08/04/22. Review of R1’s Physician Report dated 01/07/22, Preplacement Appraisal Information dated 12/10/21, and Enhanced Residential Care Services Assessment dated 01/24/22 revealed that R1 is diagnosed with depression and suicidal ideation, but it is unclear whether R1 wears diapers. UnfoundedRead the full finding— CDSS inspection report, August 11, 2022 · control 22-AS-20220804171850

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Carol Lee and explained the reason for today’s inspection. The investigation into the allegation of Facility staff member withdrew money from resident's account without authorization revealed the following: During the course of the investigation, LPA inspected the facility via tele-visit on 11/2/20 and 11/10/20, interviewed Witness #1 (W1), Resident #1 (R1), and Staff #1 (S1), and obtained and reviewed records including admission agreement, emails between witnesses, bank records, and accounting and financial records. On 11/2/20, LPA interviewed W1, confirmed allegations, and requested documents. On 11/10/20, LPA interviewed R1 who stated their rent at the facility is handled by the administrator, W1, and Witness #2 (W2). R1 also stated they did not give tRead the full finding— CDSS inspection report, June 21, 2022 · control 22-AS-20201027115455

Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to investigate the above allegation. LPA Velazquez was allowed entry into the facility and met with Administrator Carol Lee. On today's visit LPA Velazquez reviewed facility, staff, and resident records. LPA Velazquez also conducted interviews with staff and residents. During the course of the investigation LPA reviewed facility, staff, and resident records. Records reviewed included resident and staff rosters, staff schedules, levels of care assessment, call lights logs, resident physician's reports, identification and emergency information, resident appraisal needs and services plans, and resident admission agreements. Administrator Lee also provided copies of invoices from Clipboard Health which is the temp agency the facility used to hire temporary staff from January through March of 2022. LPA Velazquez also conducted interviews with staff and residents who were not able to corroborate the aboRead the full finding— CDSS inspection report, May 6, 2022 · control 22-AS-20220210124439

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Carol Lee, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff did not respond to a resident's call light in a timely manner revealed the following: During the course of the investigation, LPA inspected the facility’s kitchen, common areas, hallways, and 9 resident rooms, interviewed 3 staff and 6 residents, and requested and reviewed the resident roster, staff roster, staff schedule, photographs of insects at the facility, and pest control records. The investigation into the allegation that staff did not respond to Resident #1’s (R1) call light in a timely manner revealed the following: SubstantiatedRead the full finding— CDSS inspection report, April 15, 2022 · control 22-AS-20220408162727