198603162-5-30-2023-28-AS-RORN-CSLQ8H-20230608115646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 05/30/2023
Date Signed: 05/30/2023 03:31:53 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
05/22/2023 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230522092621

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: 73	DATE:	05/30/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Michael Forsgren		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff misrepresented himself as the Administrator
Staff issued an eviction notice to a resident without obtaining licensee’s authority

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegations. LPA met with Operations Manager, Michael Forsgren, who assisted with today's visit.

Regarding the allegation that : Staff misrepresented himself as the Administrator, the investigation consisted of interviews with Administrator, Staff #1 - Staff #3, and Resident #1 - Resident #6. Staff #1 stated that he is the Operations manager, and has not sent any letters to resident(s) stating that he is the Administrator. He denied that he has misrepresented himself as the administrator. Staff #1 provided a copy of current business card, and staff roster which indicates that he is the Operations Manager. Administrator stated that Staff #1 is the authorized person designated to represent the facility when Administrator is unavailable. LPA obtained a copy of the Designation of Facility Responsiblity form, which designates staff #1. Staff interviewed were unable to corroborate the allegation. They stated that staff #1 is the Operations manager, and staff #1 has not sent any letters to resident(s) indicating that he is the administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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-20230522092621

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: 05/30/2023

NARRATIVE

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Residents interviewed were unable to corroborate the allegation. They stated that they have not received a letter from staff #1 stating that he is the Administrator.

Regarding the allegation that : Staff issued an eviction notice to a resident without obtaining licensee’s authority. The investigation consisted of interviews with Administrator, Staff #1 - Staff #3, and Resident #1 - Resident #6. Administrator, and Staff interviewed denied the allegation. Administrator and Staff #1 indicated that Staff #1 is the authorized person designated to represent the facility when Administrator is unavailable. Staff #2 and Staff #3 were unable to corroborate the allegation, they stated that they did not have any knowledge of specific resident eviction notice(s). LPA observed that Staff #1 is authorized by the facility to issue eviction notices when the Administrator is not available. LPA observed that the eviction issued to Resident #7 met title 22 regulations. Residents interviewed were unable to corroborate the allegation. Residents interviewed did not have any knowledge of specific resident eviction(s).

Based on LPA's observations and interviews, investigation revealed: 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 allegations are unsubstantiated.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC9099 (FAS) - (06/04)

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