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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 04/21/2023
Date Signed: 05/17/2023 10:52:51 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/20/2023 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230320125600
FACILITY NAME:WHITTIER GLEN ASSISTED LIVINGFACILITY NUMBER:
198603162
ADMINISTRATOR:HIPOLITO, RHONWINNFACILITY TYPE:
740
ADDRESS:10615 JORDAN RDTELEPHONE:
(562) 943-3724
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:93CENSUS: 68DATE:
04/21/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Wellness Director, Sherrie SimiltonTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Inadequate staff supervision resulting in resident being assaulted by another residents
Staff spoke inappropriately to resident
Facility is unlawfully evicting resident
Staff did not safeguard resident’s personal items
Staff did not provide meals to resident
INVESTIGATION FINDINGS:
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********This is an amended version of the original report created on 4/21/2023*****. This report is being amended to remove confidential information. No other changes have been made to the report.************

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint investigation for the allegations listed above. LPA met with Staff #5 (S5) and explained the reason for the visit. LPA Pena spoke with the Operations Manager, Michael Forsgren on the phone to discuss the purpose of today's visit as he is out of the office. S5 will be assisting LPA with the investigation during today's visit.

On 03/28/2023, LPA Pena conducted the initial complaint investigation which included: tour of the facility; R1’s room, the dining room and common areas. LPA reviewed and obtained copies of Resident #1 (R1) files. LPA also obtained various documents from the facility files such as: Staff/Resident Roster, House rules, Eviction notices (02/21/2023 & 03/16/2023), Police report #23-1597, Unusual Incident/Injury Report dated 3/16/2023 with Administrator Self-reported SOC 341, list of Staff Training and Monthly Meal menu. Interviews were conducted with Resident #2 (R2)-Resident #8 (R8) and Staff #1 (S1)-Staff #4 (S4).

During today's visit, LPA Pena obtained copies of the Staff & Resident Rosters, Unusual Incident/Injury Reports dated 02/07/2023 & 02/16/2023, toured the facility, and interviewed Staff #5 (S5) and Staff #6 (S6).
****CONTINUED ON LIC9099-C*****
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
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 4
Control Number 28-AS-20230320125600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WHITTIER GLEN ASSISTED LIVING
FACILITY NUMBER: 198603162
VISIT DATE: 04/21/2023
NARRATIVE
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The investigation revealed the following:

Regarding allegation: "Inadequate staff supervision resulting in resident being assaulted by another residents." It is alleged that R1 has been assaulted by different residents and a night staff on separate occasions. Interviewed staff members denied the allegation and stated that they always have problems with R1. Staff members indicated that R1 was always drunk and blame other people for his drinking problems by making up stories. Interviews conducted with R2 and R8, stated that the allegation was untrue. R2 stated that he never accosted R1 nor grabbed and spilled his food. R8 stated that he never dragged R1 from his legs and tried to hit him. The investigation revealed that local law enforcement responded to the facility on the evening of 03/15/2023 regarding a resident (R1) that had a knife on the 2nd floor. S2 was doing her rounds and observed R1 inebriated in his wheelchair and was arguing with residents. S2 asked R1 to return to his room, and R1 fell asleep on the way to his room. At approximately 9:00pm, S2 received a call from the local Police Dept. regarding a resident that had a knife. S2 immediately responded and found other residents using a table to block R1 from attacking them with a 6-inch knife. R2-R5 who were witnesses to the incident stated that R1 woke up and became aggressive, produced a knife and R2-R3 started defending R4-R5 and themselves. R1 received a laceration on his nose due to a table used in defense. No one else was injured during the incident. Police then arrived on scene and subdued R1. Paramedics arrived shortly after and R1 was taken to the hospital for medical treatment. S1 stated that PD refused to take R1 into custody due to R1 being in a wheelchair, but police report indicated that R1 will be cited for assault with a deadly weapon. On 3/16/2023, R1 was discharged from the Hospital and returned to the facility. S1 stated that he has made several calls to R1's Social Worker to assist with new placement but was unsuccessful. W1 confirmed S1's statement and added that W1 was also active in looking for another place for R1. Files reviewed indicated that on 2/21/2023, the facility issued a 30-day eviction notice to R1 due to prior history of verbal and physical threats against other residents, staff, police and paramedics while inebriated. On 3/16/2023, R1 has been issued a 3-day eviction notice due to being a danger to himself and others and was approved by CCLD on 3/20/2023. On 03/22/23, R1 was moved out of the facility to a medical clinic . Interviewed residents stated that R1 was the aggressor physically and verbally. Some residents stated that they were never assaulted or was spoken inappropriately by other residents or staff. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230320125600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WHITTIER GLEN ASSISTED LIVING
FACILITY NUMBER: 198603162
VISIT DATE: 04/21/2023
NARRATIVE
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Regarding allegation: "Staff spoke inappropriately to resident." It is alleged that a resident was unable to sleep so he went to the hallway when a night staff yelled and cursed at him and told him to go back into his room. Interviews conducted with staff denied the allegation and indicated that they do not speak inappropriately, use profanity nor yell at residents. All staff members also indicated that they have not heard or witnessed anybody speaking inappropriately to residents. S2 and S4 denied speaking inappropriately to residents, or knowledge of any staff working during the day or night shift addressing R1 or any residents in an inappropriate manner. S2 stated that she was doing her rounds one night and observed R1 inebriated in his wheelchair and was arguing with residents. S2 asked R1 to return to his room, but she did not curse or yell at R1. Staff members also indicated that they receive monthly in-service training related to Residents Rights and Personal Rights. Residents interviewed indicated that they have not heard staff using profanity and staff do not yell at them. Residents also indicated that staff communicate with them in a respectful manner. Therefore there was insufficient evidence to corroborate with these allegation.

Regarding allegation: "Facility is unlawfully evicting resident." It is alleged that on 3/16/2023, resident was advised that there were witnesses that he was the aggressor and that he had to leave and has until 3/23/23 to do so. And that the resident was asked to sign a document which he refused to sign and was not provided with anything in writing. Documents reviewed revealed that the facility issued eviction notices to R1. A 30-day eviction notice was issued on 02/21/2023 due to R1's previous history of verbal and physical threats against other residents, staff, police and paramedics while inebriated, breaking the house rules regarding alcoholic beverage and R1 was behind on his monthly rent payments. Additionally, S1 stated that based on R1's Physician's report, R1 cannot leave the facility unassisted. But R1 continued to leave the facility unassisted. LPA reviewed the Physician's report and confirmed the note. Another incident occurred on 3/15/2023 wherein R1 brandished a knife which demonstrated that he was a danger to himself and others. Due to this latest incident, S1 issued a 3-day eviction notice to R1 on 3/16/2023. CCLD approved the 3-day eviction notice and a copy was also sent to Dept. of Health Care Services. On 3/20/2023, S1 along with W1 provided R1 with a copy of the 3-day eviction notice which R1 refused to sign nor keep a copy for himself. LPA reviewed R1's facility file and confirmed that eviction notices were issued to R1 on 2/21/2023 and 3/16/2023. LPA also reviewed R1's Admission Agreements which stated Eviction Procedures and House rules acknowledged and signed by R1. Based on LPA review of documents and statements gathered from interviews conducted there was not enough supportive evidence to concur with the reported allegation.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230320125600
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: WHITTIER GLEN ASSISTED LIVING
FACILITY NUMBER: 198603162
VISIT DATE: 04/21/2023
NARRATIVE
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Regarding allegation: "Staff did not safeguard resident’s personal items." It is alleged that the staff did not have an explanation as to what happened to the resident's food and liquor (valued at $20) and $10 in cash that was left in his room. 4 out of 6 staff interviewed revealed that they saw the bottle of alcohol in R1’s room but did not see or know anything about the food and $10 cash. Staff members stated that staff would not have thrown any of the resident’s belongings. The facility's procedure is that the staff will secure and pack residents personal belongings when they leave the facility. Then wait for instruction as to where the belongings will be sent out to or forwarded. S1-S2 stated that when R1 left, they packed R1's belongings including the bottle of alcohol, put them in a box and held it, but did not know anything about the food and the $10 cash. S1 stated that they have already sent R1's personal belongings to R1's new place approximately 2 weeks ago. 7 out of 8 interviewed residents stated that none of their items have gone missing and they would tell staff if their items went missing. Residents also stated that facility staff safeguard their belongings and personal items. Residents indicated that they don’t have a problem with missing items and they feel safe leaving their items in their rooms. Some residents also stated that they lock their doors so nothing has happened or issues with missing items. Staff interviews, resident interviews and reviewed documentation do not corroborate this allegation.

Regarding allegation: "Staff did not provide meals to resident." It is alleged that on 3/18/2023, a resident was not given dinner, and on 3/19/23, resident was not provided with breakfast, lunch, and dinner. The resident was physically unable to leave the room to get his meals and staff did not want to bring him his meals to the room. Staff interviewed stated that the allegation is untrue. Staff members stated that there is plenty of foods for residents and meals are provided 3x daily, breakfast, lunch and dinner. S2 stated that she brought R1's food to his room personally after the incident. S2 also brought food (breakfast, lunch) to R1's room on 3/17/2023 & 3/18/2023. S1 stated that care staff takes meal attendance to make sure all residents get their meals. None of the staff members interviewed can corroborate R1's statement that someone brought him food for dinner on 3/19/2023. Staff members also indicated that the facility provides monthly menu to residents and if the resident does not like what's served, they have an alternate menu also. Staff can also bring food trays in the residents room for an extra fee. R2-R8 stated that the facility provide meals, and they get monthly menu as well as the alternate menu. Some residents go to the dining area to eat, but if they cannot, then they order it by phone or by filling out a slip and food can be picked up or delivered to their room. LPA reviewed the monthly menu and alternate menu. LPA also observed residents eating in the dining area and a staff passing out medication with a check list of residents who are present in the dining area. Documentation reviewed and interviews conducted do not corroborate this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations.

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.

An exit interview was conducted, and a copy of this report was provided to the Wellness Director, Sherrie Similton.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4