<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 05/23/2023
Date Signed: 05/24/2023 08:18:05 AM

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
03/04/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210304103655
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: 73DATE:
05/23/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Wellness Director Sherrie SimiltonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have a Certified Administrator
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation for the allegation(s) above. LPA met with Wellness Director Sherrie Similton and the purpose of the visit was discussed.

Initial visit conducted 3/12/21 LPA Villalobos interviewed Resident #1 (R1) Staff #1 (S2) and Staff#2 (S2). LPA requested copies of the following: Staff Roster as well R1's Physicians report, Needs and Services plans, Medication Records for March and February of 2021, and Admissions Agreement.

On todays visit, LPA interviewed Staff #3-#5 (S3-S5) and residents #2-6 (R2-R6). The investigation revealed the following:

In regards to the allegation "Facility does not have a Certified Administrator" it was alleged that the facility does not have an active administrator. (2) of (5) Staff interviewed denied the allegation. (3) of (5) Staff interviewed could not provide information regarding the allegation.

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: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
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
03/04/2021 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210304103655

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: 73DATE:
05/23/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Wellness Director Sherrie SimiltonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide alternative toileting resources for a resident

Facility is not obtaining renewed medication timely
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation for the allegation(s) above. LPA met withWellness Director Sherrie Similton and the purpose of the visit was discussed.

Initial visit conducted 3/12/21 LPA Villalobos interviewed Resident #1 (R1) Staff #1 (S2) and Staff#2 (S2). LPA requested copies of the following: Staff Roster as well R1's Physicians report, Needs and Services plans, Medication Records for March and February of 2021, and Admissions Agreement.

On todays visit, LPA interviewed Staff #3-#5 (S3-S5) and residents #2-6 (R2-R6). The investigation revealed the following:

In regards to allegation "Facility staff did not provide alternative toileting resources for a resident" it was alleged that R1 did not have a working toilet in their room from 2/26/21-3/1/21 and was not provided alternative toileting needs. (5) of (5) Staff interviewed denied the allegation.

Continued on LIC 9099-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: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
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-20210304103655
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: 05/23/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff show that low pressure toilets were being changed in the facility to replace them with better ones. No toilet was broken or non operational and all residents in rooms where the bathroom toilets were being changed, were provided with assistance in using other restroom toilets or commodes if they preferred. Interviews with R1 show that staff provided R1 with a commode and there were other restrooms in the facility for R1 to use. R1 used the commode with staff assistance. Based on interviews conducted; Although the allegation 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.

In regards to the allegation "Facility is not obtaining renewed medication timely" it was alleged that the facility staff is not receiving and providing R1 with their medication in a timely manner. (5) of (5) Staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews show that R1 contacted his physician for medication changes. R1's family member picked up new medications and dropped them off to R1 without notifying the facility staff. S1 stated that R1 is not able to handle their own medication and so they had a conversation with R1 regarding medication management and that staff cannot provide R1 with the new medication unless they also confirm the physicians order for it. Once the medication order was confirmed, staff began to provide R1 with the medication. Staff denied not obtaining R1's medication in a timely manner. Based on interviews and file review conducted; Although the allegation 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 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: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210304103655
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: 05/23/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(6) of (6) Residents interviewed could not corroborate the allegation. Interviews and file review show that administrator Mona Tirado last day at the facility was on 2/12/21. Between 2/12-3/10 there was an interim administrator Lori Waters assisting the facility, but documents for change of administrator were not provided to Licensing in this time. It was not until May 2021 when Licensing received documentation for change of Administrator to Sophia Chan. This shows that facility failed to maintain a qualified and currently certified administrator. Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are 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: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210304103655
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: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2023
Section Cited
CCR
87405(a)
1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator....

This was not met as evidenced by:
1
2
3
4
5
6
7
Facility Administrator to review Title 22 Regulations regarding 87405 Administrator - Qualifications and Duties and submit letter to LPA signed and dated by POC due date.
8
9
10
11
12
13
14
Adminstrator Mona Tirado left the facility on 2/12/21 and was not replaced by a full time Administrator until 5/2/21. This poses a potential health and safety risk to residents in care and supervision.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5