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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 03/14/2023
Date Signed: 03/14/2023 04:46:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/06/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230306081511
FACILITY NAME:WHITTIER GLEN ASSISTED LIVINGFACILITY NUMBER:
198603162
ADMINISTRATOR:HIPOLITO, RHONWINNFACILITY TYPE:
740
ADDRESS:10615 JORDAN RDTELEPHONE:
(562) 943-3724
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:93CENSUS: 63DATE:
03/14/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Operations Manager Michael ForsgrenTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility staff member asked resident to lend them money and never paid them back.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint investigation for the allegation listed above. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed.

On today's visit , LPA interviewed Staff #1-5 (S1-S5) and Residents #1-#6 (R1-R6) and collected the following documents: Copies of documents from R2's file, Staff and Resident Roster, Staff file for S5, and copy of the food menu for March. The investigation concluded the following:

In regards to the allegation "Facility staff member asked resident to lend them money and never paid them back" it was alleged that S1 borrowed money from R1 and did not return their money. (5) of (5) Staff interviewed denied the allegation. (5) of (6) Residents could not corroborate the allegation. Interviews and file review show that S1 no longer works in the facility as of 2/9/23. Interview with R1 states that S1 borrowed money from R1 sometime in January 2023.....

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/06/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230306081511

FACILITY NAME:WHITTIER GLEN ASSISTED LIVINGFACILITY NUMBER:
198603162
ADMINISTRATOR:HIPOLITO, RHONWINNFACILITY TYPE:
740
ADDRESS:10615 JORDAN RDTELEPHONE:
(562) 943-3724
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:93CENSUS: 63DATE:
03/14/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Operations Manager Michael ForsgrenTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility staff does not provide resident(s) an adequate quantity of food.
Facility staff does not respond to residents’ call buttons in a timely manner.
Facility staff retaliates against residents for making complaints.
Facility staff are not ensuring safety of residents' personal possessions.
Facility staff member did not respect residents' privacy by knocking on their door before entering their room.
Facility staff did not seek a resident timely medical attention.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint investigation for the allegation listed above. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed.

On today's visit , LPA interviewed Staff #1-5 (S1-S5) and Residents #1-#6 (R1-R6) and collected the following documents: Copies of documents from R2's file, Staff and Resident Roster, Staff file for S5, and copy of the food menu for March. The investigation concluded the following:

In regards to the allegation "Facility staff does not provide resident(s) an adequate quantity of food.", it is alleged that the facility is not providing enough food to residents and sometimes it runs out before everyone gets a meal. (5) of (5) staff interviewed denied the allegation. (4) of (6) Residents interviewed could not corroborate the allegation. LPA reviewed the facilities food menu for the day and observed lunch being served during the time of visit. LPA observed adequate portion and nutritious meals being served.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20230306081511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/14/2023
NARRATIVE
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Interviews with staff show that residents are offered seconds after everyone has received a meal and residents can request different meals ahead of time also. Interviews do not show that the facility runs out of meals or refuses to provide other options to residents. Based on interviews, observations and files reviewed; 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 allegation is unsubstantiated.

In regards to the allegation "Facility staff does not respond to residents’ call buttons in a timely manner. " it was alleged that staff will take long to address residents call button. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews with residents detail staff responses from call buttons to be anywhere between 2-10 minutes depending on how busy staff can be. During the visit and unknown to staff, LPA entered room #207 and pulled the emergency cord. Staff arrived within 2 minutes to check in on residents of that room because of the pull cord. Interviews with staff state that no emergency signals are ignored. Based on interviews and observations; 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 allegation is unsubstantiated.

In regards to the allegation "Facility staff retaliates against residents for making complaints." it was alleged that facility staff neglect the care of residents because of residents that make complaints. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews do not show that staff retaliate against residents for making complaints. Interviews with staff state that they will always listen to resident complaints and address any issue. LPA did not observe residents being neglected at the time of the visit. Based on interviews and observations; 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 allegation is unsubstantiated.

In regards to the allegation "Facility staff are not ensuring safety of residents' personal possessions." it was alleged that there has been theft of clothes, radios, and small amounts of cash at the facility. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews do not show that there have been witnesses to acts of stealing in the facility. LPA was not provided with a name of who was stealing items in the facility.....

Continued on LIC 9099-C
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20230306081511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/14/2023
NARRATIVE
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(1) of (6) residents interviewed stated clothes has gone missing from their possession but was not sure who took it. Staff interviews deny stealing any personal possessions from residents in care. Based on interviews and observations; 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 allegation is unsubstantiated.

In regards to the allegation "Facility staff member did not respect residents' privacy by knocking on their door before entering their room." it was alleged that S2 enters residents rooms without knocking or permission. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews show that staff will go from room to room for multiple reason throughout the day. There are clients who need assistance with medication, assistance with grooming, and assistance in room cleaning. Staff will also conduct room checks when residents are not responsive to door knocks. Interview with S2 denies that they have ever entered a residents room without knocking and identifying first. LPA was not provided with proof of S2 entering resident rooms unannounced. During the visit, LPA observed S2 knock on doors and announce themselves before entering. Based on interviews and observations; 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 allegation is unsubstantiated.

In regards to the allegation "Facility staff did not seek a resident timely medical attention." it was alleged that facility staff did not call 911 in a timely manner for R2. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. File review shows that R2 had a fall in the dinning room on 3/1/23 and also receives assistance from a hospice agency. Incident report collected states that the resident received first aid and their hospice agency was contacted and also was taken to the hospital. Interview with R2 corroborates the information on the incident report. Interviews show that S3 immediately assisted and assessed R2 then contacted responsible parties. Hospice agency determined it would be best for R2 to go to the hospital and so they were taken. During interview, R2 stated they agreed to wait for the hospice agencies decision about going to the hospital. Based on interviews, observations, and files reviewed; 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 allegation is unsubstantiated.

Exit Interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20230306081511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2023
Section Cited
CCR
87208(a)(5)
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87208.Plan of Operation.(a) Each facility shall have and maintain a current, written definitive plan of operation...The plan and related materials shall contain the following:(5) Staffing plan, qualifications and duties.

This was not met as evidenced by:
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Facility to provide inservice training on the plan of operation policies to staff and create a plan to address borrowed money incident between R1 and S1, by POC due date.
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S1 borrowed money from R1 and did not return their money. This is against the facilites staff handbook which is part of the plan of operation, and poses a potential health and safety risk to residents in care and supervision.
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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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20230306081511
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/14/2023
NARRATIVE
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LPA reviewed the facilities employee handbook which states staff are too not borrow money from residents. No other staff or residents were aware of the incident. LPA observed text communication between R1 and S1 that shows details of S1 borrowing money and acknowledging that they owe R1. This shows that during their employment at the facility, S1 did not abide by the facilities plan of operation. 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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6