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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 07/06/2022
Date Signed: 07/06/2022 03:54:54 PM

Unsubstantiated


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
11/22/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211122141422
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: 53DATE:
07/06/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Pamela Junge TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff not abiding to admission agreement
Staff did not advise residents of complaints filed against the facility
Resident is being charged for services not received
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Jose Villalobos and Mary Flores conducted a subsequent complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Administrator Pamela Junge. Purpose of the visit was discussed.

Initial visit was conducted on 12/1/21 and consisted of the following: LPA interviewed Staff #1 (S1) and Resident #1 (R1). LPA toured the physcial plant and room #229. LPA reviewed and collected copies of R1's resident file. LPA also recieved a copy of the staff and resident roster.

On Todays visit , LPA interviewed Staff #2-#5 (S2-S5) and Resident #2-#5 (R2-R5). LPA reviewed and collected copies of R1's resident file.

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: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
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 5
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
11/22/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211122141422

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: 53DATE:
07/06/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Pamela Junge TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide a copy of the admission agreement
Facility has inadequate record keeping for the residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose Villalobos and Mary Flores conducted a subsequent complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Administrator Pamela Junge. Purpose of the visit was discussed.

Initial visit was conducted on 12/1/21 and consisted of the following: LPA interviewed Staff #1 (S1) and Resident #1 (R1). LPA toured the physical plant and room #229. LPA reviewed and collected copies of R1's resident file. LPA also received a copy of the staff and resident roster.

On Todays visit , LPA interviewed Staff #2-#5 (S2-S5) and Resident #2-#5 (R2-R5). LPA reviewed and collected copies of R1's resident file. Staff #6 could not be interviewed as they are no longer in the facility.

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: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
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 5
Control Number 28-AS-20211122141422
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: 07/06/2022
NARRATIVE
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The investigation revealed the following: In regards to the allegation, "Staff did not provide a copy of the admission agreement " it was alleged that the facility staff did provide an copy of R1's admission agreement when requested by family. (5) of (5) staff interviewed denied the allegation. (4) of (5) residents could not corroborate the allegation. Interviews show that a copy of R1's admission agreement was requested by relatives of R1 and were not provided by staff. Interviews show that R1 provided the facility staff with a letter stating that R1 gives their relative permission to receive such information. LPA observed the letter on file which was dated on 9/28/21. LPA's initial visit was conducted on 12/2/21 where the admissions agreement had yet to be provided to the relative that requested the agreement, this shows that the staff failed to provide the admissions agreement when requested.

In regards to the allegation, "Facility has inadequate record keeping for the residents" it was alleged that the facility could not provide a breakdown of R1's current pay rate as stated in the admissions agreement. (5) of (5) staff interviewed denied the allegation. (4) of (5) residents could not corroborate the allegation. Interviews show that R1's pay rate according to their admissions agreement Schedule A is $1300. Interviews state that R1's rate was calculated by adding $1200 as the base monthly fee and $100 for assisted living level of care rate. R1 has been receiving medicine management since they were admitted and that is defined as "level 1" care in the admissions agreement. R1's admissions agreement on file does not show the breakdown of the 1300 explained during interviews and staff interviewed were not able to explain why it did not show on the admissions agreement. Due to this discrepancy, the facility failed to have adequate record keeping of R1's file.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore the allegation(s) are found to be substantiated. California Code of Regulations, Title 22, citations are being cited on the attached LIC 9099D.

A copy of this report was provided to Administrator Pamela Junge. Appeal rights were discussed and provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20211122141422
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: 07/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2022
Section Cited
CCR
87507(e)
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87507.Admission Agreements.(e)The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative...The licensee shall provide additional copies to the resident or resident’s representative upon request.
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Administrator to provide licensing with a letter stating that they have reviewed title 22 section 87507 by POC due date.
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This was not met as evidenced by:

R1's family requested a copy of the admissions agreement as of 9/28/21 after R1 stated to staff to provide it and facility did not provide it. This poses a potential health and safety risk to clients in care.
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Type B
07/22/2022
Section Cited
CCR
87507(g)(3)(A)
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87507 Admission Agreements (g) Admission agreements shall specify the following:(3) Payment provisions, including the following: (A) Rate for all basic services... Basic services rate(s), including: 1. A comprehensive description of any items and services provided.. This was not met as evidence by:
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Administrator to provide licensing with a letter stating that they have reviewed title 22 section 87507 by POC due date.
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R1's admissions agreement did not have a break down of how R1s rate was calculated and staff interviewed were not able to explain. This 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: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20211122141422
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: 07/06/2022
NARRATIVE
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The investigation revealed the following: In regards to the allegation, "Staff not abiding to admission agreement" it was alleged that the facility is raising the rate for R1 and did not provide a notice as required. (5) of (5) staff interviewed denied the allegation. (4) of (5) residents could not corroborate the allegation. Interviews show that R1 was provided a 60 Day notice of the rate change in August 2021 prior to the new rate taking place on November 2021. LPA reviewed R1's file and observed the notice dated and signed by S1. Based on observations, interviews and files reviewed there was not enough supportive evidence to corroborate with the reported allegation.

In regards to the allegation, "Staff did not advise residents of complaints filed against the facility " it was alleged that the staff did not inform residents of complaints against the facility. (5) of (5) staff interviewed denied the allegation. (4) of (5) residents could not corroborate the allegation. Interviews do not show that staff inform residents of complaints on the facility but licensing reports are posted with other required postings for residents to see. Review of title 22 regulations do not state that staff need to inform residents of complaints filed against the facility. Based on interviews and file review conducted, there was not enough supportive evidence to corroborate with the reported allegation.

In regards to the allegation, "Resident is being charged for services not received " it was alleged that R1 is not being provided the services required per the admissions agreement. (5) of (5) staff interviewed denied the allegation. (4) of (5) residents interviewed could not corroborate the allegation. Interviews show that R1 receives assistance with medication, is provided 3 meals a day, has help with laundry, and has their room cleaned by staff. Review of R1's file does not show other services being paid for and not provided by the facility. Based on observations, interviews, and files reviewed, there was not enough supportive evidence to corroborate with the reported allegation.

Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED.

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

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5