198603162-11-2-2020-28-AS-FFIS-C3BSZW-20210524141951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 11/02/2020
Date Signed: 11/02/2020 04:00:46 PM

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
07/24/2020 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200724105403

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	ATEAIAN, KIMIA		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 868-9761
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 58	DATE:	11/02/2020
		UNANNOUNCED	TIME BEGAN:	01:00 AM
MET WITH:	Administrator Mona Tirado		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Licensee did not provide resident's records to the authorized representative upon written request

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos initiated a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Mona Tirado.

The initial visit was completed on 7/31/2020 with administrator Mona Tirado. On that date, LPA interviewed Administrator and staff #1 (S1), LPA toured the facility, reviewed Residents #1's (R1) file. LPA also reviewed emails related to allegation and requested a copy of R1's file for review. LPA unable to interview R1 due to R1 moving out of state.

Today's visit consists of the following: LPA delivered findings to administrator.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020

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-20200724105403

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: 11/02/2020

NARRATIVE

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The investigation revealed the following: in regards to the allegation "Licensee did not provide resident's records to the authorized representative upon written request", it was alleged that in May 2020 Resident #1's (R1) power of attorney (POA) , via a written request, requested the licensee provide R1's resident records but has yet to do so. Upon reviewing R1's records, and interviewing Administrator, there is no POA or responsible party listed in R1's records. At the time of investigation there was no documentation proving that R1 has a POA or an authorized representative. Based on interviews and documents collected, there was not enough supportive evidence to corroborate with the reported 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.

Exit interview was conducted with Administrator Mona Tirado, and a hard copy was provided via email for signature

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020

LIC9099 (FAS) - (06/04)

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