198603162-7-30-2026-28-AS-FFIS-DWWMP5-20260813094635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 07/30/2026
Date Signed: 07/30/2026 07:00:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
04/08/2026 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260408143644

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	BARBA AGUIRRE, ITZAYANA		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 84	DATE:	07/30/2026
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Itzayana Barba Aguirre, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident developed multiple pressure injuries in care due to staff neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation on the allegation listed above. LPA met with Administrator Itzayana Barba Aguirre and explained the purpose of the visit.
The investigation consisted of the following: On 4/9/26, LPA E. Mallett conducted the initial visit. Mallett toured the facility, obtained copies of the staff and resident rosters, and pertinent files for Resident #1. There were no immediate health and safety concerns noted. It was determined that the allegation requires further investigation. During the course of the investigation, a total of seven (7) Staff and eight (8) Residents were interviewed.

The investigation revealed the following: Allegation - Resident developed multiple pressure injuries in care due to staff neglect. It is alleged that Resident #1 (R1) did not receive the appropriate level of care and supervision, resulting in R1 developing multiple pressure injuries.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260408143644

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WHITTIER GLEN ASSISTED LIVING	FACILITY NUMBER: 198603162
	VISIT DATE: 07/30/2026

NARRATIVE

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The Department investigated the allegation and collected hospital medical records, interviewed staff and residents to determine the findings. The hospital medical records obtained indicated that R1 was admitted to the hospital on 4/7/26 due to chronic diarrhea and was diagnosed with stage II pressure injury on the sacral area with redness on the heels and a scrape on the right shoulder. R1 was discharged back to the facility on 4/14/26. R1 returned to the hospital on 4/24/26 for back pain and vertigo. The pressure injury on his sacrum was still noted as a stage II. The redness on the bi-lateral heels was noted as stage I. R1’s medical concerns were addressed, and returned to the facility on 4/26/26.

Interviews with Staff revealed that R1, who moved in on 3/26/26, was observed with a pressure injury or redness on the sacral area and a scrape on the shoulder. Staff acknowledged that R1 had lots of back pain and assisted the resident with transferring and repositioning regularly. Staff often checked R1 during bed baths and changes and did not observe the redness in the sacral area getting worse while R1 was residing at the facility. Staff noted that R1 was in and out of the hospital multiple times and discharge paperwork did not indicate any pressure injuries. Caregivers and Med Techs are instructed to document and report to the Wellness Coordinator(s) if they observe any changes to the residents and/or their wounds. According to R1’s care plan and progress notes, there were no indications of pressure injuries nor wound care being provided by a home health agency. R1’s physician’s report dated 3/20/2026 also did not note any pressure injuries.

Interview with R1 revealed that the resident moved into the facility with an existing pressure injury on the sacral area and an abrasion on the shoulder. R1 stated that the staff regularly assisted the resident with repositioning while in bed since R1 was unable to move onto the side due to back pain. R1 did not believe the wounds got worse or developed any new pressure injuries since living at the facility. R1 believed that the needs are being met. The additional seven (7) residents interviewed indicated that staff check on them and assist them with their needs. One of the residents who developed a pressure injury was being treated by a home health agency. Staff were also monitoring to ensure that the wounds did not worsen. Based on the information gathered, staff repositioned R1 regularly and conducted body checks. The facility documents did not note or confirm any areas with pressure injuries.

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 allegation is UNSUBSTANTIATED.

An exit interview was conducted with the administrator. A copy of this report, along with the appeal rights, was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026

LIC9099 (FAS) - (06/04)

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