198603162-1-18-2023-28-AS-RORN-CNNM3K-20230202081514

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 01/18/2023
Date Signed: 01/18/2023 04:09:14 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/23/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221223121344

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	ATEAIAN, KIMIA		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 60	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Michael Forsgren - Operations Manager		TIME COMPLETED:	04:23 PM

ALLEGATION(S):

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Staff did not ensure that a needs appraisal was conducted for resident upon admission
Facility does not currently have a certified administrator

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Michael Forsgren (Operations Manager) and explained the reason for the visit.

The investigation consisted of the following: On 12/29/2022, LPA obtained copies of staff & resident rosters, facility December 2022 menu and alternative menu, administrator certificate application and course completed, and interviewed the Operations Manager. LPA also obtained copies of R1's appraisal/needs and service plans, physician report, admission agreement, admission record/face sheet, 60 day notice of monthly rate increase dated 08/20/2021, 30 day eviction notice dated 12/20/2022, emails between facility and R1's power of attorney and account balance. Today’s visit, LPA obtained a copy of resident and staff rosters, interviewed Staff 1 – Staff 3 (S1 – S3) and Resident 1 – Resident 7 (R1 – R7), obtained copies of face sheets, pre-appraisal and appraisal/needs and services plan for R1 – R7, and toured the kitchen.
(CONTINUED TO LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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 6

Control Number 28-AS-20221223121344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/18/2023

NARRATIVE

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The investigation revealed the following: regarding the allegation "staff did not ensure that a needs appraisal was conducted for resident upon admission”, it is alleged that facility did not do a pre-appraisal and appraisal/needs and services plan for R1 upon admission. Interview with the Operations Manager revealed that per their records R1 was admitted on 10/10/2019 and a pre-appraisal and appraisal/needs and services plan was completed on 11/27/2019. The Operations Manager was hired on 11/16/2022 and thus could not provide a reason why the pre-appraisal and appraisal/needs and services plan was completed a month after R1’s admission. Staff interviewed could not provide a reason either. Residents interviewed could not corroborate with the allegation. LPA reviewed R1’s pre-appraisal and appraisal/needs and services plan and confirmed that the pre-appraisal and appraisal/needs and services plan was completed on 11/27/2019 and that R1 was admitted on 10/10/2019.

Regarding the allegation "facility does not currently have a certified administrator”, it is alleged that the Operations Manager does not have an administrator certificate. Interview with the Operations Manager revealed that he was hired on 11/16/2022 and the earliest administrator courses were available on 12/02/2022 – 12/04/2022 and 12/09/2022 – 12/11/2022. He completed the courses and submitted his administrator application on 12/17/2022. LPA reviewed the administrator certificate application, courses completed and proof of submission to Community Care Licensing Division Administrator Certification Section, and confirmed the Operations Manager's statement.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 28-AS-20221223121344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/27/2023 Section Cited CCR 87456(a)(2)	1 2 3 4 5 6 7	87456 Evaluation of Suitability for Admission (a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility is to ensure that Title 22 Section 87456 regulations are met at all times. Additionally, a statement indicating facility understands and will comply with Title 22 Section 87456 will be submitted to CCLD by 01/27/2023.
	8 9 10 11 12 13 14	Based on interviews and records reviewed the licensee did not comply with the section cited above which poses a potential risk to the health, safety, or personal rights of the persons in care. R1's pre-appraisal and appraisal/needs and services plan was not completed prior to being admitted.	8 9 10 11 12 13 14
Type B 01/27/2023 Section Cited CCR 87406(a)	1 2 3 4 5 6 7	87406 Administrator Certification Requirements (a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Facility is to ensure that Title 22 Section 87406 regulations are met at all times. Additionally, a plan to comply with Title 22 Section 87406 will be submitted to CCLD by 01/27/2023.
	8 9 10 11 12 13 14	Based on interviews and records reviewed the licensee did not comply with the section cited above which poses a potential risk to the health, safety, or personal rights of the persons in care. The Operations Manager did not have an administrator certificate prior to being employed.	8 9 10 11 12 13 14	The Operations Manager has already completed the administrator courses and submitted the administrator application to Community Care Licensing Division Administrator Certification Section on 12/27/2022.

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
12/23/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221223121344

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	ATEAIAN, KIMIA		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 60	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Michael Forsgren - Operations Manager		TIME COMPLETED:	04:23 PM

ALLEGATION(S):

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Illegal eviction
Staff retaliated against resident for excercising their right to be involved in the residents council
Staff did not allow resident to participate in planning their care
Facility failed to provide nutritious meals
Facility did not provide documents requested to relative

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 28-AS-20221223121344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/18/2023

NARRATIVE

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The investigation revealed the following: regarding the allegation "Illegal eviction". Interview with the Operations Manager revealed that an eviction notice was served to R1 and R1' relative who is R1's power of attorney on 12/20/2022 with an effective date of 01/19/2023.The reason for eviction is due to non-payment of the full monthly care fee. R1's has accrued a balance of $4862.42 dating back to January 2022. The total monthly rate for R1 is $1725, but R1 has only paid $1300. Interview with R1 revealed that they are not paying the $425 difference until the facility explains the reason for the increase because her care needs have not changed and therefore an increase should not have occurred. LPA reviewed the 60 day notice dated 08/20/2021 that was given to 35 residents including R1 with the reason why the increase occurred which was "the cost of labor continues to increase, and Covid-19 have also added increased cost for cleaning supplies and needed personal protective equipment (PPE) for staff". LPA confirmed that the eviction notice was submitted to the Community Care Licensing Department on 12/20/22. Reviewed of the eviction notice shows that it is a lawful eviction per Title 22 Section Code 87224 and R1 refused to sing it.

Regarding the allegation "staff retaliated against resident for exercising their right to be involved in the residents council", it is alleged that R1 was elected as the president of the resident's council in May 2021 and the facility retaliated with an increase in the monthly care fee effective 10/20/2021 and with the eviction notice served on 12/20/2022. Operations Manager and staff interviewed denied the allegation. Operations Manager explained that the monthly care fee increased for 35 residents not just R1 and they provided a 60 day notice on 08/20/2021 with the reason which was "the cost of labor continues to increase, and Covid-19 have also added increased cost for cleaning supplies and needed personal protective equipment (PPE) for staff". The eviction notice was served because a balance accrued due to R1 not paying the full monthly care fee. .

Regarding the allegation "staff did not allow resident to participate in planning their care", it is alleged that R1 was presented with an care plan around September 2022 and she was not included in creating the care plan. It is also alleged that R1 does not recall getting a care plan when she was admitted to this facility. Interviewed with Operations Manager and staff revealed that per their records a care plan was created, reviewed and signed by R1 on 11/27/2019 (R1 was admitted 10/10/2019). They also stated that an update was made to the care plan on 10/08/2022 and was presented to R1 for review and signature, but R1 refused to signed it and did not provide a reason. Interview with R1 revealed that R1 does not remember reviewing or signing a care plan on 11/27/2019. R1 stated that R1 refused to signed the care plan provided to her in Spetember or October 2022 because R1's relative told R1 not to sign it. Interviews with the other 6 residents revealed that they could not corroborate with the allegation. LPA reviewed care plan dated 11/27/2019 and R1 signed it and the updated 10/08/2022 care plan R1 refused to sign it. (CONTINUED TO LIC 9099C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 28-AS-20221223121344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/18/2023

NARRATIVE

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Regarding the allegation "facility failed to provide nutritious meals", it is alleged that the facility is not providing a balance nutritious meal because most meals have only carbs. Operations Manager and staff interviewed denied the allegation. Interviews with residents revealed that 5 out of 7 residents could not corroborate with the allegation. LPA toured the kitchen during lunch time and observed that the meal being served contain a good balance of protein, carbs and veggies.

Regarding the allegation "facility did not provide documents requested to relative", it is alleged that R1's relative requested documents and the facility did not provided the documents. Operations Manager denied the allegation and stated all documents pertaining to R1 were handed to 2 of R1's relative that came to pick up the documents on 11/23/2022. Operations Manager also stated that R1's relative has requested corporate internal documents and documents with information about other residents and these are the documents they can't provide to R1's relative. The documents provided on 11/23/2022 were R1's billing records from 10/10/2019 to present and entire health record. Residents interviewed revealed that 6 out of 7 residents could not corroborate with the allegation. LPA reviewed a document signed by R1's relatives that picked up the documents on 11/23/2022.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview held and a copy of the report was provided

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6