Whitten Heights Assisted Living and Memory Care

Based on observations, there were multiple areas in the facility's two memory care units, especially Room 259, which smelled strongly of urine, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED

Based on documents, the facility has been conducting emergency disaster drills annually, and not quarterly as required, which poses a potential safety risk to persons in care.

Based on documents, the physician's reports for R1, R6, and R9 are on the old form and do not contain required information, including behavioral expressions, which poses a potential safety risk to persons in care.

Based on observation, the water temperature tested at 122 degrees F in Room 122, 125 degrees in Room 347, and 124 degrees in room 341, which poses a potential safety risk to persons in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.... This requirement was not met as evidenced by: Based on photographs, observations, and interviews, the licensee did not ensure dog feces are timely cleaned up in the central outdoor courtyard resulting in residents not being able to enjoy their outdoor space, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

87224 Eviction Procedures (b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit… This requirement was not met as evidenced by: Based on interviews, the licensee told R1 they would be evicted via 3-Day Eviction when the 3-Day Eviction was withdrawn by the licensee and not approved, which poses an immediate personal rights risk to persons in care.

(a) The pre-admission appraisal, as specified in Section 87457.., shall be updated, in writing as frequently as necessary... This requirement was not met as evidence by there was no appraisal conducted for R1 and therefore facility cannot meet needs that are not identified. This poses an immediate health and safety risks to persons in care.

(f) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... This requirement was not met as evidence by R1 did not have a care plan for fall mitagation which resulted in resident sustaining multiple falls due to neglect. This poses an immediate health and safety risks to persons in care.

(a) Each licensee shall furnish to the licensing agency ...:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which theatens... the welfare, safety or health of any resident... This requirement was not met as evidence by there was no incident report for R1's hospitalization in December 2023. This poses a potential health and safety risks to persons in care.

87468.1(a)(2) – 87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on observations, the licensee did not ensure residents were able to enjoy healthful and comfortable accommodations by not cleaning, repairing, or replacing multiple stained and torn furniture items, which poses a potential personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

87307 Personal Accommodations and Services (d) … (2) The premises... shall provide a safe and healthful environment. This requirement was not met as evidenced by: Based on admission and observations, the licensee did not ensure messes in the third-floor memory care are cleaned appropriately and timely by not providing immediate access to appropriate cleaning chemicals to caregivers and allowing caregivers to leave messes for the housekeepers to clean up hours later, which poses a potential health risk to persons in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times…. This requirement was not met as evidenced by: Based on admission and observations, the licensee did not ensure two out of three elevators were functional and accessible, with one elevator being non-functional for over a year and another elevator being obstructed, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

87468.1 Personal Rights … (a) … (11) To have their visitors… permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure R1 was able to enjoy the right of visitation by calling the police on W1 for staying past visiting hours, which poses an immediate personal rights risk to persons in care.

87468.2 … Personal Rights … (a) … (8) To be free from …mental … abuse. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure residents were free from mental abuse when S1 yelled at them, which poses an immediate personal rights risk to persons in care.

87468.1 Personal Rights… (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure residents were accorded dignity when multiple staff engaged in rudeness, mockery, and ignoring resident inquiries, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on admission and observations, the licensee did not ensure residents can safely and comfortably enjoy the facility by not properly enforcing the facility’s smoking rules resulting in verbal altercations between residents and visitors and R1, which poses an immediate personal rights risk to persons in care.

87458 Medical Assessment(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed... and made within the last year.This requirement is not met as evidence by: Based on interviews, record review and observations, R1, R2, R3, R4 have not recieved an updated medical evaluation. R1's physican report is dated for 5/18/22, R2's physican report is dated for 3/28/23, R3's physican report is dated for 3/24/23 and R4's physican report is dated for 3/28/23. This poses an immediate Health and Safety risk to residents in care.

87458 Medical Assessment(c) The medical assessment shall include...(1) ...results of an examination for...(A) Communicable tuberculosis.This requirement is not met as evidence by: Based on interviews, record review and observations, R2 and R3 did not complete a tuberculosis screening. This poses an immediate Health and Safety risk to residents in care.

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement is not being met as evidenced by: FR1 was evicted for being inappropriate with women after being accused of groping R1.

87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below… This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure multiple reportable incidents were reported as required, which poses a potential safety risk to persons in care.

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R2 received care and supervision for their aggressive behavior resulting in R1’s injury, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first…This requirement was not met as evidenced by: Based on documents, the licensee did not ensure R2 was reappraised at least yearly, which poses a potential safety risk to persons in care.

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations...This requirement was not met as evidenced by: 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.

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure one resident received care and supervision by having to wait approximately one hour for assistance with using the bathroom due to short staffing, which poses an immediate health risk to persons in care.

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: 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.

Based on documents, the staff files for 5 out of 10 staff did not have health screenings, which poses a potential safety risk to persons in care.

Based on documents, it has been more than three months since the facility's last emergency disaster drill, which poses a potential safety risk to persons in care.

Based on documents, the licensee did not maintain complete records for annual training requirements for 10 out of 10 staff, which poses a potential health risk to persons in care.

Based on Guardian records and admission, the licensee did not ensure staff VERONICA DIAZ VILLEGAS was background cleared prior to working at the facility for multiple years and that staff Dolores L Gonzalez was associated prior to working at the facility for multiple months, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

Based on documents and admission, the current administrator's administrator certificate lapsed on February 5, 2025, which poses a potential safety risk to persons in care.

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This req is not being met as evidenced by: Based on observation, Licensee failed to ensure facility is in good repair. LPA observed noted items on LIC 9099. This poses a potential health and safety risk to residents in care.

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... ... 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.

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on interviews and observations, the licensee did not ensure residents are able to safety and comfortably enjoy their rooms and interior spaces of the facility by not properly enforcing the facility’s smoking rules, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

87468.1 Personal Rights… (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews and observation, the licensee did not ensure residents are encouraged to wear shoes and that staff do not make fun of residents, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure the facility was safe and sanitary when R1’s room was infested with roaches, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.

87219 Planned Activities(f)In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities,...The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. This requirement was not met as evidence by: Based on interviews and records reviewed the facility does not have a full-time Activities Director. This poses a potential health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: LPA observed ripped couches with brown and black discoloration, LPA observed that the wood floor is broken and missing parts of the tiles, LPA observed chipped tables, tables missing paint and chairs with ripped plastic covers, LPA observed that the baseboards throughout the facility are chipped and have brown and/or black discoloration and on the first floor LPA observed that the dryer is missing the top cover which exposes the flame. This poses a potential health, safety or personal rights risk to persons in care

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on interviews and record review, the black dog became a tripping harzard for R1 causing R1 to trip and fall on 10/06/24 which poses a potential Safety Risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not being met as evidenced by: Interview confirmation and observation that revealed Resident 1 smokes cigarettes inside their room.This poses a potential health and safety risk to residents in care.

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: Based on documents and interviews, the licensee did not ensure the medications for 5 out of 5 residents were documented on the MAR as being given as prescribed, which poses a potential health risk to persons in care.

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision ... for the safety and well-being of residents, employees and visitors. This req is not being met as evidenced by: Based on observation and interviews conducted, the Licensee failed to ensure facility is clean and sanitary. LPA observed cockroaches and ants in resident rooms. This poses an immediate health and safety risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not being met as evidenced by: Interview confirmation and observation that confirm Resident 1 smokes cigarettes in their room.This poses a potential health and safety risk to residents in care.

87507 Admission Agreements … (g) Admission agreements shall specify the following: (4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change... This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not provide at least 60 days’ notice of a rate change to residents, which poses a potential personal rights risk to persons in care.

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes... or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by, the facility did not notify R1's responsible party of the bruise on their right arm. This poses a potential health and safety risk to residents in care.

To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by; On December 3, 2023 facility staff wore a sweatshirt "hoodie" that said, "F - U" on it. This poses a potential health and safety risk to residents in care.

(f) A facility shall have both of the following in place:(1) An evacuation chair at each stairwell, on or before July 1, 2019.This requirement is not being met as evidenced by... LPA observed that none of the 4 stairwells in the facility had an evacuation chair. This poses an immediate Health and Safety risk to residents in care.

Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided...This requirement is not being met as evidenced by: Based on interview and record review, Licensee failed to ensure R1's records were provided as requested. This poses a potential health and safety risk to residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ... residents ... shall have all of the following personal rights: (26) To manage their financial affairs... This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not ensure R1 was able to manage their financial affairs by withdrawing money from R1's bank account without authorization, which poses an immediate personal rights risk to persons in care.

87303 Maintenance and Operation (i) … (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit… This requirement was not met as evidenced by: Based on interviews, facility staff did not respond to R1’s call light in a timely manner, which poses an immediately health and safety risk to residents in care.

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on interviews and documents, the facility did not provide R1 the care and supervision they required as evidenced by R1’s multiple attacks on residents/staff and the injuries R1 also sustained in some altercations, which poses an immediate safety and personal rights risk to persons in care.

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. … This requirement was not met as evidenced by: Based on interviews and documents, the facility did not reappraise R1’s care needs for two (2) years despite R1’s change of condition and increased aggression which began in late 2019, which poses an immediate safety and personal rights risk to persons in care.

87307 Personal Accommodations and Services: … (d) …: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by: Based on observation, the licensee did not ensure carpets were free from fall hazards including tears, holes, gaps, and mounds on all 3 floors, which poses a potential health safety risk to residents in care.

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by: Based on observation, the licensee did not ensure carpets were free from stains and possible mold on all 3 floors, which poses a potential health and safety risk to residents in care.