198603162-5-4-2023-28-AS-BPEA-CRJ9HJ-20230504232313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 04/13/2023
Date Signed: 05/04/2023 11:23:13 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
04/06/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230406095433

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: 66	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Operations Manager, Michael Forsgren		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not providing a safe environment for residents in care.

INVESTIGATION FINDINGS:

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********This report supersedes the original report created on 4/13/2023. Reason for supersede is to ensure report is visible on transparency website. Findings have not changed.***********

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Operations Manager, Michael Forsgren and explained the reason for the visit.

The investigation consisted of the following: LPA requested copies of Resident & Staff Rosters and conducted a tour of facility and common areas. LPA reviewed files for Resident #1 (R1) - Resident #2 (R2) and requested copies of the following documents: Identification and Emergency Information Sheets, Physician Reports, Resident Appraisals, and Incident Report (4/04/2023). At 1:48pm, LPA interviewed Resident #1 (R1) telephonically. LPA also interviewed Resident #2 (R2) - Resident #5 (R5) and Staff #1 (S1) - Staff #4 (S4).

The investigation revealed the following: In regards to the allegation "Staff are not providing a safe environment for residents in care.", it is alleged that a resident is being threatened by another resident in the facility because of his religion. Interviews conducted with 4 out of 4 staff members all denied the allegation. All staff members interviewed indicated they have not seen or witnessed R2 made inappropriate comments or threatened other residents due to their religion. *****CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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-20230406095433

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: 04/13/2023

NARRATIVE

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S1 stated that he investigated this incident after it was reported to him by R1. According to S1, he spoke to the alleged perpetrators R2-R3, who both denied the allegation and stated that they did not threaten any residents due to their religion. S1 indicated that R1 has been making confused allegations. All staff members confirmed that Easter Service was conducted at the facility on Easter Sunday, attended by residents and staff. S1 confirmed that there was an incident on 4/04/2023 which involved R2 and R5. The incident indicated that R2 hit R5 with his wheelchair and this was reported to CCLD. Facility staff also called the police and 911. S1 stated that statements were taken by the police and will be assessed for further action, no arrests were made. S1 stated that he spoke to R2 and gave him a warning that if he continues to exhibit this type of behavior and that it would result in eviction. Interviews conducted with 4 of 5 residents indicated that R2 has never intimidated, threatened or attacked them. R2 stated that the wheelchair incident was an accident and did not mean to harm anybody intentionally. 4 out of 5 residents interviewed indicated that they feel safe and comfortable in the facility. During the facility tour, LPA observed that residents were socializing and get along well with each other in the common areas.

Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation.

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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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