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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004192
Report Date: 03/27/2025
Date Signed: 03/27/2025 02:10:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/13/2025 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250113112051
FACILITY NAME:WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306004192
ADMINISTRATOR:STEVE SHENFACILITY TYPE:
740
ADDRESS:200 WEST WHITTIER BLVD.TELEPHONE:
(562) 691-1200
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:196CENSUS: 119DATE:
03/27/2025
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Faye ShenTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Facility staff are not dispensing medications as prescribed
INVESTIGATION FINDINGS:
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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 Chief Operating Officer (COO) Faye Shen and explained the reason for today’s inspection.

The investigation into the allegation that facility staff are not dispensing medications as prescribed revealed the following: During the course of the investigation, LPA inspected the facility, interviewed residents and staff, and obtained and reviewed copies of the resident roster, staff roster, the facility’s Medication Administration Records (MAR), the facility’s as-needed medication logs, and resident medication lists.

It was alleged that instead of giving residents their prescribed pain medications, facility staff are giving alternate medications, smaller doses, or skipping medications altogether, and there is concern about theft of these medications.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
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 22-AS-20250113112051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 306004192
VISIT DATE: 03/27/2025
NARRATIVE
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LPA interviewed the facility’s medication technician supervisor who reported there were issues in December 2024 with residents on controlled pain medications but denied that any of these medications have been stolen. LPA reviewed the facility’s MAR for December 2024 for the five residents on controlled pain medications and noted the MARs are incomplete and do not properly document the medications dispensed. Per the facility’s medication technician supervisor, the facility is using a new electronic MAR system which does not always record the information that is entered, but the facility’s as-needed medication logs are still handwritten and properly document medications dispensed. LPA inspected the controlled pain medications for the five residents, all of which were in bubble packs, and observed no errors. LPA reviewed the January 2025 as-needed medication logs for the three residents who take controlled pain medications on an as-needed basis and confirmed the logs matched the medications administered and that there were no missing or extra pills. The facility’s medication technician supervisor denied that residents were ever given smaller doses than prescribed, but revealed that in December 2024 one of these residents missed one or two doses and was offered an alternate medication (Tylenol) because the facility ran out of supply of the resident’s controlled pain medication. LPA reviewed this resident’s medication list and confirmed Tylenol is one of their prescribed medications. Per the facility’s medication technician supervisor, this resident requests and takes this controlled pain medication four times a day. LPA reviewed this resident’s as-needed medication logs and noted approximately six days in November and December 2024 when the resident missed at least one dose of their controlled pain medication. LPA also noted that these logs did not document the facility’s attempts to refill the medication, which dates and times the medication could not be provided as requested, and the reason the medication could not be provided as requested. LPA inspected the medications for an additional 10 residents and did not observe any additional medication issues. LPA interviewed two additional medication technicians and did not obtain additional information regarding the allegation. LPA interviewed the four residents on controlled pain medications who were present at the facility and did not obtain additional information regarding the allegation. The information obtained corroborated that the facility did not dispense one resident’s medications as prescribed by running out of one of supply and that the facility instead dispensed an approved alternate medication.
During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250113112051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 306004192
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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The licensee stated they will submit a plan to ensure residents’ medications are refilled timely to LPA by POC due date.

CIVIL PENALTIES ASSESSED
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Based on documents and interviews, the licensee did not ensure one resident received assistance with medications when the facility ran out of supply and provided a doctor-prescribed alternative, which poses a potential health risk to persons in care.
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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.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3