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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603222
Report Date: 04/17/2025
Date Signed: 04/17/2025 11:40:37 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2024 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241218082122
FACILITY NAME:WHITTIER PLACE SENIOR LIVINGFACILITY NUMBER:
198603222
ADMINISTRATOR:CASTILLO,JOSHUAFACILITY TYPE:
740
ADDRESS:12315 BURGESS AVENUETELEPHONE:
(562) 777-1477
CITY:WHITTIERSTATE: CAZIP CODE:
90604
CAPACITY:125CENSUS: 68DATE:
04/17/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Memory Care Director Frances ReyesTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Due to neglect, resident sustained wounds
Staff are not ensuring residents hygiene needs are met
Staff did not provide timely medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Frances Reyes and explained the reason for the visit.
The purpose of the visit is to deliver findings from the original complaint dated 12/18/2024.
The initial visit was a Health and Safety Check conducted on 12/19/2024 and included the following:
LPA conducted a tour of the facility, including food supply, resident rooms, bathrooms, and common areas. The kitchen had sufficient perishable and non-perishable food. Resident rooms and common areas were properly furnished. LPA did not observe any immediate health and safety risks on today's visit. LPA observed the water temperature measured between 105* F - 120* F, the facility temperature was comfortable for the residents, and electricity was operational. LPA requested and obtained copies of staff and resident roster along with additional pertinent documentation.
Investigation was conducted by the Investigations Branch (IB) and completed 03/18/2025 for allegations
Due to neglect, resident sustained wounds, Staff are not ensuring residents hygiene needs are met and
Staff did not provide timely medical care for resident.
Investigation consisted of interviews with facility staff, resident, review of medical documentation and interviews with staff at Hospice Agency and Home Health Agency.
I
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
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 3
Control Number 28-AS-20241218082122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WHITTIER PLACE SENIOR LIVING
FACILITY NUMBER: 198603222
VISIT DATE: 04/17/2025
NARRATIVE
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In regards to the allegation Due to neglect, resident sustained wounds, based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility was responsible for Neglect/ Lack of Care, leading to the Resident R1 to sustain wounds while in care. Per the progress notes, on 12/14/2024, the Staff S1 documented that R1 sustained a red spot and scabbing on her right foot. On 12/15/2024, the staff S2 documented that the right dorsal surface (on R1's foot) had redness with open sores and skin lesions. She notified R1's family and her Primary Care Physician (PCP). On 12/16/2024, R1 was taken to the hospital for an evaluation and treatment by her sister. Per interview with the Nurse Practitioner at St. Jude Medical Center, she stated that R1 was diagnosed with cellulitis of her right foot. She added that the wounds would be consistent with this timeline; however, it could take longer for a wound like this to advance to cellulitis. She added that this could occur from hours to days. All the staff interviewed, stated that R1 would have her socks changed daily and she would have showers twice a week. Per the Hospice Nurse and the Home Health Nurse , they both stated that the facility appeared to not be neglectful of R1. They did not believe the facility was neglectful with R1's level of care.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.
In regards to the allegation Staff did not provide timely medical care for resident, Based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility was responsible for Neglect/ Lack of Care, due to Staff not providing timely medical care for the Resident R1 while in care. Per the progress notes, on 12/14/2024, the Staff S1 documented that R1 sustained a red spot and scabbing on her right foot. On 12/15/2024, the Staff S1 documented that the right dorsal surface (on R1's foot) had redness with open sores and skin lesions. She notified R1's family and her Primary Care Physician (PCP). On 12/16/2024, R1 was taken to the hospital for an evaluation and treatment by her sister. Per interview with the Nurse Practitioner at St. Jude Medical Center, she stated that R1 was diagnosed with cellulitis of her right foot. She added that the wounds would be consistent with this timeline; however, it could take longer for a wound like this to advance to cellulitis. She added that this could occur from hours to days.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20241218082122
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WHITTIER PLACE SENIOR LIVING
FACILITY NUMBER: 198603222
VISIT DATE: 04/17/2025
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

In regards to the allegation Staff are not ensuring residents hygiene needs are met, based on interviews conducted and information gathered Resident R1 revealed that she felt happy and safe at the facility. R1 added that she enjoyed playing games with the staff and other residents, and there was nothing she disliked. R1 added that she would receive two showers weekly. R1 stated that staff would change her socks daily. R1 stated that she has a lot of nurses who would tend to her weekly.
Interview with Hospice Agency Representative who stated that “I’m a patient care advocate and I don’t hesitate to call APS, but I don’t think they (the facility) was being neglectful.” Stated that R1's foot issue was addressed by a home health agency, and she believed that the home health agency would be responsible for caring for R1's foot.
Interview with Home Health Agency representative who stated that she did not recall any foot issues with R1 as she appeared well cared for and well dressed. Her room was cleaned, and it seemed as she was showered regularly .Could not recall seeing R1 in socks as she would typically wear sandals barefoot.
Interview with Staff who stated that R1 was cared for very well by the facility and other agencies.
Stated she took 2 showers each week and did not go without socks.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3