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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004192
Report Date: 04/03/2025
Date Signed: 04/03/2025 04:47:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
03/27/2025 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250327111846
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:
04/03/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Faye Shen- Chief Operating OfficerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Licensee did not provide a healthful environment by allowing resident to smoke at the facility entranceway.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) arrived at the facility unannounced for the purpose of initiating the complaint investigation into the above allegation. LPA was greeted and granted entry by the receptionist. Chief Operating Officer (COO) Faye Shen arrived approximately 10:18am and was informed the reason for the visit. During the course of the investigation, LPA interviewed ten residents and three staff and obtained pertinent documentation which includes the resident/staff rosters, staff contacts, face sheets, physician's reports, admission agreement, resident code of conduct, and smoking log from January 16, 2025 to today's date. LPA is unable to qualify three resident interviews due to their medical condition or language barriers.

Regarding the allegation, Licensee did not provide a healthful environment by allowing resident to smoke at the facility entranceway, the investigation revealed the following: Approximately 8:30am, LPA smelled cigarette odor from the entrance area and observed Resident #1(R1) smoking in the front patio. LPA observed cigarette buds on the ground and R1 smoking throughout the day at 9:39am, 10:05am, and 1:56pm.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
03/27/2025 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250327111846

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:
04/03/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Faye Shen- Chief Operating OfficerTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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3
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9
Licensee did not provide a safe environment.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) arrived at the facility unannounced for the purpose of initiating the complaint investigation into the above allegation. LPA was greeted and granted entry by the receptionist. Chief Operating Officer (COO) Faye Shen arrived approximately 10:18am and was explained the reason for the visit. During the course of the investigation, LPA interviewed ten residents and three staff and obtained pertinent documentation which includes the resident/staff rosters, staff contacts, face sheets, physician's reports, admission agreement, resident code of conduct, and smoking log from January 16, 2025 to today's dates. LPA is unable to qualify three resident interviews due to their medical condition or language barriers.

Regarding the allegation, Licensee did not provide a safe environment, it was alleged that Resident #1 (R1) was making threats and yelling at the entranceway. Based on the interviews, six out of the seven residents and three out of the three staff confirmed R1 yelling or talking loudly to oneself as a result of their medical/mental health condition. However, the six residents indicated not feeling threatened or witnessing other residents or visitors being threatened by R1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20250327111846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306004192
VISIT DATE: 04/03/2025
NARRATIVE
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The three staff also indicated R1 expressing anger only when told not to smoke in the front patio.

Due to conflicting information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Licensee did not provide a safe environment is deemed Unsubstantiated.

An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report was provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20250327111846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations...

This requirement was not met as evidenced by:
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Administrator stated that the facility will move forward with the eviction of R1 and will provide the eviction notice to LPAs Cho and Haddad via email by POC due date.
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Based on observations and interviews, the licensee did not ensure residents are able to safely and comfortably enjoy the facility by not properly enforcing the facility’s smoking rules, which poses a potential personal rights risk to persons in care. CIVIL PENALTY ASSESSED for repeated violation.
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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: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20250327111846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306004192
VISIT DATE: 04/03/2025
NARRATIVE
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Six out of the seven residents and three out of the three staff interviews acknowledged R1 smoking in the front patio which is a no smoking zone evidenced by the two no smoking signs and one personal sign posted for R1. Three out of the three staff indicated reminding R1 not to smoke, however R1 would not adhere to the house rules. Based on the review of the resident code of conduct, facility enforces a strict zero-tolerance policy and permits smoking "exclusively in designated areas" and prohibits in areas marked with no smoking signs. Per review of the the resident's smoking log, which was part of the Plan Correction (POC) issued on January 15, 2025, the log reveals R1 smoking at the front entrance.

Based on the observations made, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Licensee did not provide a healthful environment by allowing resident to smoke at the facility entranceway is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC9099D. A civil penalty for a repeat violation is being assessed on the LIC421FC.

An exit interview was conducted with Chief Operating Officer Faye Shen, and a copy of this report including the LIC811 and the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5