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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 10/27/2022
Date Signed: 04/29/2023 01:10:30 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
03/21/2022 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220321101032
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: 55DATE:
10/27/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Pamela JungTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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9
Resident's diapering needs were not met.

Resident's hygiene needs are not being met.
INVESTIGATION FINDINGS:
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This is an amended 9099 report of the original report dated 10/27/2022. The purpose of the amended report is to clarify and identify resident(s) that were interviewed.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by the new Administrator (A2: Pamela Jung). LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation(s). An initial 10-Day visit was conducted by LPA Angelica Rea on 03/28/22 with (then) Administrator (A1: Sophia Chan), Staff #1, Staff #2, Staff #3, and Resident #2.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
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 3
Control Number 28-AS-20220321101032
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: 10/27/2022
NARRATIVE
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LPA/RA Ceniceros interviewed (between 8:15 a.m. - 9:30 a.m.) two (2) staff members (A2 and S2), in care. Resident #1 could not be re-interviewed as the resident was transferred to a skilled-nursing facility following hospitalization on (03/20/22). LPA/RA Ceniceros reviewed (between 9:30 a.m. – 10:15 a.m.) the requested documents: Admissions Agreement (dated 12/30/21), Emergency I.D. & Information (dated 12/30/21), Physician’s Report (dated 12/21/21), Pre-placement Appraisal (dated 12/30/21), ALWP ISP (dated 07/20/21),
Functional Capability Assessment (dated 04/13/22) for Resident #1 (R1); Staff & Residents' rosters; "Care Companion" program app (via iPhone).

Regarding Allegation #1: this investigation revealed based on interviews conducted corroborated that the facility staff alternates diapering needs every two (2) hours. A review of R1's Assisted-Living Waiver Program's (ALWP) Individual Service Plan (ISP) documented under: Need/Concern: Participant is at risk of incontinence due to periods of weakness and diminished physical functioning (Pg 9 of 12). A review of R1's Admission Agreement on Pg 19 documented: Full Level 4 Care: Toileting. A review of R1's Physician Report documented under: Physical Health Status: Yes bowel and bladder impairment; Able to care for toileting needs? No. Facility utilizes a "Care Companion" program app (via iPhone) to monitor all residents who require full-service care; and, via cell phone (w/the program app) is assigned to the "on-duty" caregivers and med techs who documents their entries once a resident has been checked for incontinence care. [LPA/RA Ceniceros observed the Care Companion program app demonstration (via Staff #2's assigned cell phone.)]

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident's diapering needs were not met is found to be UNSUBSTANTIATED.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220321101032
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: 10/27/2022
NARRATIVE
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Regarding Allegation #2: this investigation revealed based on interviews conducted corroborated that the caregivers provide hygiene needs to the residents that require full-service care. A review of R1's Assisted- Living Waiver Program's (ALWP) Individual Service Plan (ISP) documented under: Physical / Health: Requires assistance to complete ADLs (Pg 7 of 12). A review of R1's Admissions Agreement (Pg 19) documented: Full Level 4 Care: Assistance with grooming. A review of R1's Physician Report documented under: Physical Health Status: Att risk if allowed direct grooming and hygiene items? Yes; under: Capacity for Self Care: Able to groom self? No. Facility utilizes a "Care Companion" program app (via iPhone) to monitor all residents who require full-service care; and, a cell phone (w/the program app) is assigned to all "on-duty" caregivers and med techs who documents their entries once a resident has been checked for hygiene needs. [LPA/RA Ceniceros observed the "Care Companion" program app demonstration (via Staff #2's assigned cell phone.)]

Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident's hygiene needs are not being met is found to be UNSUBSTANTIATED.

An exit interview was conducted and a copy of the Complaint Report provided to Medication Technician, Katie McDonald.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3