198603162-2-2-2023-28-AS-TVAO-CP2V3X-20230214150529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 02/02/2023
Date Signed: 02/02/2023 02:54:48 PM

Unsubstantiated

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
06/30/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220630153013

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:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Michael Forsgren - Operations Manager		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are not honoring resident privacy during resident council meetings
Staff did not assist resident with medical treatment after resident informed staff of falling
Facility failed to report resident's incident pet Title 22 reporting requirements.
Facility is falsifying incident reports.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint visit regarding the above allegation(s). LPA Flores met with Michael Forsgren Operations Manager and explained the reason for the visit.

The investigation consisted of the following: On 7/6/22 The visit consisted of the following: LPA Flores requested a copy of the resident/staff roster. LPAs Flores and Villalobos interview resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6) and staff #1(S1),#2(S2),#3(S3), LPA Flores reviewed R1's file and requested the following copies; physician report dated 9/26/19 and 5/9/22, identification and emergency information, unusual incident report, personal rights residential care facilities for the elderly, needs and care assessment plan dated 5/7/2019. On 7/8/22 LPA requested a copy of hospital discharge, and incident report from family representative. On 1/27/23 LPA Flores interview staff #4(S4) and attempted to interview staff #5(S5) and #6(S6).

(CONTINUED LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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-20220630153013

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: 02/02/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation Staff are not honoring resident privacy during resident council meetings. It is alleged staff member assigned to take notes during the Residents' Council Meeting was providing names of residents filing issues/problems with the administration. Interviews conducted with residents revealed, 2 out of 6 residents interview stated to have been or are involved in the resident council meeting and the only staff present is the activity director, who has been invited to assist with taking minutes for the residents. 2 out of 6 residents are aware there is a resident council meeting but do not participate in it and have not heard of privacy/confidentially not being provided during the meetings. 1 out of 6 residents did not know much about the resident council meeting. Interview with Executive Director revealed activity director types the notes taken during the meetings and provides the information of repairs needed in order for the facility to address them without identifying the residents. Interviews with staff revealed 2 out of 3 staff stated not to be a part of the council meeting and 1 out of 3 staff stated to have been assisting with the council meeting since July 2022, takes notes and types the minutes. Documents reviewed revealed Resident Council Meeting Minutes for January 2022 - June 2022 have notes of topics discuss in each meeting with suggestions from residents and a response from each department which is shared with the residents.

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.

Regarding allegation: Staff did not assist resident with medical treatment after resident informed staff of falling. It is alleged resident #1(R1) had taken a serious fall outside the facility and R1 had to call 911 her/himself to get any help. Interviews with residents revealed 3 out of 6 residents interview stated to have received assistance when medical care has been needed and emergency medical technicians (EMTs) were contacted to transport residents to the hospital when needed. 2 out of 6 residents stated to have not required medical assistance and/or had fall but are aware they will obtain assistance if necessary. Interview with R1 revealed that on 6/28/22 R1 had fallen around 3:00am in the morning outside the facility. R1 returned inside the facility on their own. Upon staff assisting R1, staff asked R1 if they should call 911 to which R1 responded to staff, "not to see a need to call". R1 change her/his mind and choose to call 911 on their own. Interview with executive director revealed it is facility's policy to contact 911 if a resident sustains a head injury and night staff stated R1 stated to have fallen on her knees and pointed at forehead when describing the fall, no injuries were noted by night staff. Interviews with 3 out of 3 staff interview stated it is procedure to call 911 if residents sustained a head injury. During document review it was observed unusual incident report dated: 7/1/22 notes R1 fell outside the facility approximately at 3:00am. (CONTINUED ON LIC 9099C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220630153013

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: 02/02/2023

NARRATIVE

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Med Tech offered to send R1 out to the hospital and declined at the time but R1 call 911 later. Physician's Report dated: 5/9/22 notes R1 is able to leave the facility unassisted and to communicate needs on their own. Personal Rights signed on 10/10/19 note R1 has the right to receive and reject medical care.

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.

Regarding allegation: Facility failed to report resident's incident pet Title 22 reporting requirements and Facility is falsifying incident reports. It is alleged resident reported to Med-Tech about a fall, staff refused to take a report and facility's staff failed to sign accident report. Interviews with residents revealed, 5 out of 6 residents interview stated facility maintains documentation and when necessary family or responsible party are notify of incidents and have no concerns regarding facility's documentation. 1 out of 6 residents stated an incident report was not provided to the resident until 6-7 days after the incident occurred. Executive Director stated an unusual incident report was created and submitted to the department within 7 days per regulation. Interviews with staff revealed 3 out of 3 staff stated facility creates unusual incident report to submit to the department within 7 days, no other reports are provided to residents and facility notifies responsible parties of any incident. Documents reviewed reveal unusual incident report dated: 7/1/22 was submitted to the department on 7/4/22 report was submitted by, reviewed, and approved by Executive Director Pamela Junge.

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.

Exit interview was conducted with Michael Forsgren Operation Manager and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

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