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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004192
Report Date: 02/14/2025
Date Signed: 02/14/2025 11:28:01 AM

Document Has Been Signed on 02/14/2025 11:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306004192
ADMINISTRATOR/
DIRECTOR:		STEVE SHENFACILITY TYPE:
740
ADDRESS:200 WEST WHITTIER BLVD.TELEPHONE:
(562) 691-1200
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 196CENSUS: 120DATE:
02/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:Faye Shen, COO TIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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On this day Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit in conjuction with complaint control #22-AS-20241219124149. LPAs were greeted and granted entry into the facility and explained the reason for the visit.

During the investigation for complaint control 22-AS-20241219124149 it was revealed that Resident 1 (R1) hospice records were not available. It was also reported by 2 out of 2 staff that R1's hospice does not provide updates or care plans to the facility.

Based on observations made during today's visit a deficiency is being cited per Title 22 An exit interview was conducted and a copy of this report was provided along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2025 11:28 AM - It Cannot Be Edited


Created By: Andrea Mendivil On 02/14/2025 at 10:19 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2025
Section Cited
CCR
87632(a)(4)

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a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency....(4) A statement by the licensee that an agreement with the hospice agency will be entered into regarding the care plan for the terminally ill resident...
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COO agrees to retain all hospice records and to hold a meeting with hospice for R1
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 ... to be accepted and/or retained in the facility. (4)The agreement with hospice shall design and provide for the care, services, and necessary medical intervention related to the terminal illness.. This requirement was not met as evidence by R1's hospice records were not available.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
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