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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 03/10/2023
Date Signed: 03/10/2023 04:22:14 PM

Substantiated


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
01/17/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230117134559
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: 63DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Operations Manager Michael Forsgren TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not notify Licensing of covid positives in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint visit for the allegation above. LPA met with Michael Forsgren (Operations Manager) and explained the reason for the visit.

Initial visit conducted on 1/25/23 consisted of the following: LPA interviewed Staff #1-#2 (S1-S2) and Residents #1-#4 (R1-R4). LPA toured the physical plant of the facility. LPA collected a copy of the staff and resident roster. LPA collected documents related to covid outbreak from the facility and observed required postings around the facility.

On Todays visit, LPA interviewed Staff #3-5 (S3-S5) and residents #5-6 (S5-S6). The investigation revealed the following:

In regards to the allegation "Facility did not notify Licensing of covid positives in a timely manner" it was alleged that the facility did not notify licensing of all covid positives in a timely manner....

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: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
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
01/17/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230117134559

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: 63DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Operations Manager Michael Forsgren TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not follow isolation/ quarantine procedures for covid positive residents
Facility did not notify residents of covid outbreak in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint visit for the allegation above. LPA met with Michael Forsgren (Operations Manager) and explained the reason for the visit.

Initial visit conducted on 1/25/23 consisted of the following: LPA interviewed Staff #1-#2 (S1-S2) and Residents #1-#4 (R1-R4). LPA toured the physical plant of the facility. LPA collected a copy of the staff and resident roster. LPA collected documents related to covid outbreak from the facility and observed required postings around the facility.

On Todays visit, LPA interviewed Staff #3-5 (S3-S5) and residents #5-6 (S5-S6). The investigation revealed the following:

In regards to the allegation "Facility did not follow isolation/ quarantine procedures for covid positive residents" it was alleged that the facility did not properly separate covid positives residents from non positive residents. (5) of (5) staff interviewed denied the allegation...
CONTINUED ON LIC9099-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: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
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-20230117134559
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: 03/10/2023
NARRATIVE
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(5) of (6) residents interviewed could not corroborate the allegation. Interviews show that residents who tested positive for covid 19 were isolated in their rooms as there were no currently available isolation rooms to quarantine in. Interviews with S1 stated that contact with LA County Response team initially advised the facility not to move residents into different zones. It was not until 1/3/23 that the facility was contacted by Department of Health Nurse and an outbreak was declared. Facility was then advised to separate residents into red and green zones. LPA reviewed site visit from Department of Health dated 1/5/23 stated that they observed the facility to be using proper zoning strategy. Based on interviews and files reviewed; although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.

In regards to the allegation "Facility did not notify residents of covid outbreak in a timely manner" it was alleged that the facility failed to notify all residents of covid outbreak in the facility. (5) of (5) staff interviewed denied the allegation. (5) of (6) residents interviewed could not corroborate the allegation. Interviews show that the facility notified each individual and their responsible parties when the said individual would test positive. Other residents were not informed of who was positive as to not violate personal rights. Review of documentation shows that the outbreak was not declared until 1/3/23 by the Department of Public Health. Interviews show that required postings were place on the outer doors coming into the facility and around the building to notify residents and staff of the outbreak. on 1/25/23 during the initial visit, LPA observed covid 19 required postings on the main entrance to the facility as well as staff following covid 19 guidelines. Based on interviews and files reviewed; although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.

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

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230117134559
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: 03/10/2023
NARRATIVE
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(5) of (5) staff interviewed denied the allegations. (5) of (6) residents could not corroborate the allegation. File review of facility documents shows that there was an outbreak of covid positives in the facility starting in December 2022. The outbreak was declared on 1/3/23 by the Department of Public Health. LPA observed that (3) staff and (1) resident had initial positives dating back to 12/8/22, but were not reported to Licensing until 12/20/22. This shows that the facility failed to notify Licensing of covid positives in a timely manner. Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided and discussed.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230117134559
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: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
CCR
87211(a)(2)
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(a) Each licensee shall furnish to the licensing agency such reports... (2)Occurrences, such as epidemic outbreaks, ... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported... to the licensing agency and to the local health officer when appropriate.
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Facility to provide licensing report of covid positives for 12/8-12/9/22 to Licensing as well as provide documentation in letter that staff who creates incident reports has read and understands Title 22 Reporting Requirements by POC Due Date

Citation cleared at the time of visit
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This was evidence by:

LPAs review showed (3) staff and (1) resident who were covid positive on 12/8/22 were not reported until 12/20/22, this poses a potential health and safetey 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: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5