198603162-4-14-2023-28-AS-FFIS-CYZ3E5-20231229171035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 04/14/2023
Date Signed: 04/14/2023 03:07:16 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
04/10/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230410123136

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:	04/14/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Operations Manager- Michael Forsgren		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not provide resident sufficient notice prior to changing residents rate structure.
Staff interfered with the resident council book by destroying the records and replaced the book with an empty book.
Staff are not safeguarding the residents records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an initial complaint investigation visit for the allegation(s) listed above. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed.

Pre-Investigation LPM interviewed Resident #1 (R1) and Council Presdient.

On todays visit 4/14/23, LPA collected resident / staff roster, Admission Agreement, Care Update Notice on Rate Change, and billing ledger report on rate change from August 2021-November 2021.LPA took pictures of the Council Books and LPA toured with Michael the facilities Business Office, Activity Office Room, and Wellness Room. LPA Calderon interviewed Operations Manager Michael Forsgren, interviewed via telephonically Administrator Rohnwinn 'Rhon' Hipolito Staff #1-#2 (S1-S2), attempt interview Staff #3 (S3) and interviewed resident #2-#10( R2-R10).
Continuation on 9099-C...

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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 3

Control Number 28-AS-20230410123136

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: 04/14/2023

NARRATIVE

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The investigation reveled the following: regarding allegation: Staff did not provide resident sufficient notice prior to changing residents rate structure. LPA Calderon interviewed Operations Manager Michael Forsgren, Administrator Rhon Hipolito who both denied above allegation stating residents receive a 60 day notice in writing when rent it changed and sufficient notice is provided. Interview with staff, S1 and S2 were not present during the rent increase in 2021. LPA interviewed residents R3, R4, R7-R10 all denied above allegation stating they or their representative get written notification on rent increase. Interviews with R5 and R6 stated they have not encountered a facility rent increase since admission. LPA collected Rent Increase Notice that stated increase on rent will occur within 60 days of date provided on the notice letter. LPA Calderon reviewed Billing Ledger alongside with Michael and increase on rent bill occurred within 60 days of written notice. LPA reviewed facility Admission Agreement which states facility provides a written letter at least with a 60 day notice on Basic Services/ Assisted Living Services.

Regarding allegation: Staff interfered with the resident council book by destroying the records and replaced the book with an empty book. On 4/12/23 LPM Fierros and LPA Villalobos Interviewed via telephonically R1 who is not aware of the above allegation. LPA Villalobos interviewed telephonically Council President who was unaware of information regarding this allegation. LPA interviewed R2-R10 all who were not aware of a council book pertaining to the council meetings and were not aware if the book was destroyed, interfered and/or if book disappeared. LPA interviewed Michael denied the above allegation stating book staff did not interferer with the council book, it was not destroyed or did not disappear. Michael stated an additional book with residents names and responses was made for resident's privacy and minute minutes are kept in another book for residents to view. LPA Interviewed Rohn who denied the above allegation and was not aware of the council book being interfered with. Interview with S2 denied the above allegation, denied the book being interfered with in any way, S2 stated old records are kept in the Activity Office, residents minute meetings if requested S2 provides copies of meetings minutes, families and visitors have not asked to have access to the council book.

Continuation on 9099-C...

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230410123136

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: 04/14/2023

NARRATIVE

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Regarding allegation: Staff are not safeguarding the residents records. Interview with Michael, Rohn, and S1 and S2 all denied the above allegation and stated residents records are safeguard, kept behind locked doors or locked cabinets inaccessible to clients. LPA interview with residents, R7-R10 all denied above allegation records are kept safe and staff are professional. LPA observed rooms that have residents files locked when staff weren't present, records were kept in cabinets/ shelves and rooms were inaccessible to residents.

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.

Exit interview held and a copy of the report was provided

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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