198603162-3-17-2023-28-AS-VMAO-CPZVJE-20230317162837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603162
Report Date: 03/17/2023
Date Signed: 03/17/2023 04:28:45 PM

Document Has Been Signed on 03/17/2023 04:28 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	HIPOLITO, RHONWINN		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 65	DATE:	03/17/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Rhonwinn Hipolito- Executive Director & Michael Forsgren- Operations Manager		TIME COMPLETED:	02:39 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 (LPA) V. Maldonado made an unannounced visit at the facility for a case management visit in order to conduct Health and Safety check in response to an incident report received by the licensing agency on 3/16/23. LPA Maldonado met with Rhonwinn Hipolito- Executive Director (ED) & Michael Forsgren- Operations Manager (OM) and explained the purpose for the visit. During todays visit, LPA Maldonado obtained a copy of the resident and staff roster, Resident# 1's (R1) Needs and Services Plan, toured the physical plant, and conducted a health and safety check with ED and OM. Other records previously obtained by Licensing Program Manager ( LPM) Fierros for R1 are as follow: Facesheet, Physician's Report, Incident Reports for previous and current incidents with attached SOC341's, Progress Notes, Police Report, 30-Day Eviction Notice, and 3-Day Eviction Notice. The facility reported that on 3/15/23 Staff# 1 (S1) observed Resident# 1 (R1) inebriated in R1's wheelchair and was arguing with other residents. S1 asked R1 to return to their room and R1 fell asleep on the way to their room. S1 returned to do rounds to allow R1 to "sleep it off". At about 9:00PM, S1 received a call from local police department (PD) stating a resident in the facility had a knife. S1 responded the report where S1 found R1, resident# 2 (R2) and resident# 3 (R3) in the hallway near the TV room. R1 had brandished a 6" knife at R2 and R3. R2-R3 picked up a small table to block R1 from getting close to them. Residents# 4 (R4) and #5 (R5) witnessed the incident and reported that R1 became aggressive, produced the knife at R2-R3 and they defended themselves with the table, which resulted in R1 sustaining a laceration to their nose. No one else was injured during the incident. PD arrived at the facility to assess and de-escalate the situation. The paramedics arrived shortly after and transported R1 to the hospital for medical treatment. Per OM, PD refused to take R1 into custody due to being in a wheelchair, but did cite R1 for assault. R1 was discharged from the hospital and back to the facility on 3/16/23. The facility issued R1 with 30-Day eviction notice on 02/21/23 due to history of verbal and physical threats against other residents, staff, police, and paramedics, while inebriated. (Report Continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: WHITTIER GLEN ASSISTED LIVING	FACILITY NUMBER: 198603162
	VISIT DATE: 03/17/2023

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ED has made several calls to R1's social worker to assist with new placement; however, new placement has been unsuccessful. Due to this incident, R1 has been issued a 3-day eviction notice that is currently under review with the licensing agency. No media attention has been drawn to the recent incident.

During today's visit, LPA observed a sufficient supply of perishable and non-perishable foods for residents in care. LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns and no deficiencies cited.

An exit interview was conducted and a copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC809 (FAS) - (06/04)

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