<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603162
Report Date: 02/02/2023
Date Signed: 02/02/2023 02:56:19 PM


Document Has Been Signed on 02/02/2023 02:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:WHITTIER GLEN ASSISTED LIVINGFACILITY NUMBER:
198603162
ADMINISTRATOR:ATEAIAN, KIMIAFACILITY TYPE:
740
ADDRESS:10615 JORDAN RDTELEPHONE:
(562) 943-3724
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:93CENSUS: DATE:
02/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Michael Forsgren - Operation ManagerTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced case management visit to note deficiencies. LPA Flores met with and explained the reason for the visit.

During the investigation of complaint #28-AS-202206300153013 it was discovered that facility's Resident Council Meeting Minutes for January 26, 2022 reviewed notes facility's response to the resident council concerns. One of the concerns noted on 1/26/22 was regarding resident #1(R1). The response provided by facility's staff to the residents council concern provides R1 medical diagnosis/directives in the minutes taken which violates the personal rights of the resident. Resident Council Meeting minutes are provided to residents upon request.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Michael Forsgren Operation Manager an a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/02/2023 02:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: WHITTIER GLEN ASSISTED LIVING
FACILITY NUMBER: 198603162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2023
Section Cited

1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a) ...residential care facilities for the elderly shall have... personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will ensure staff is properly train on section 87468.2 Personal Rights - maintaining personal information confidential for Residents in care and will submit a plan for training by POC due date 2/3/23 and a copy of training and signing logs by 2/9/23.
8
9
10
11
12
13
14
Based on documents reviewed Licensee did not ensure medical diagnosis/directives were maintain confidential for residents in care which poses an immediate health, safety, or personal rights violation for the residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2