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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 07/21/2023
Date Signed: 07/21/2023 03:57:18 PM

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
05/08/2023 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230508083627
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: 75DATE:
07/21/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Michael Forsgren - Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to meet resident’s medical needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tena Herrera conducted a follow up complaint investigation regarding the allegations listed above. LPA met with Executive Director Michael Forsgren and explained the reason for the visit.

The investigation revealed the following: during the initial visit conducted on 5/15/23, LPA Kruz Long obtained a copy of the Staff/Resident rosters, Resident Council book and interviewed Resident #1 to #6 in room #101.

The investigation revealed the following: during subsequent visit conducted today 7/21/23, LPA Tena Herrera obtained the following documents: Staff Roster, Resident Roster, Resident file for R11 (physician report, admissions information, discharge information, medication list), Employee file for S1 (traini ngs, signed policy and procedures) quality guidelines for skin evaluation, and resident house rules. LPA also conducted
(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
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 5
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
05/08/2023 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230508083627

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: DATE:
07/21/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Michael Forsgren - Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff verbally abused resident while in care.
Staff failed to treat resident with dignity and respect.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tena Herrera conducted a follow up complaint investigation regarding the allegations listed above. LPA met with Executive Director Michael Forsgren and explained the reason for the visit.
The investigation revealed the following: during the initial visit conducted on 5/15/23, LPA Kruz Long obtained a copy of the Staff/Resident rosters, Resident Council book and interviewed Resident #1 to #6 in room #101.

The investigation revealed the following: during subsequent visit conducted today 7/21/23, LPA Tena Herrera obtained the following documents: Staff Roster, Resident Roster, Resident file for R11 (physician report, admissions information, discharge information, medication list), Employee file for S1 (trainings, signed policy and procedures) quality guidelines for skin evaluation, and resident house rules. LPA also conducted interviews with Executive Director Michael Forsgern, Staff # 2-4 (S2-S4) and Resident # 7-11
(Continued on 9099-A
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230508083627
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: 07/21/2023
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
(R7-R11). LPA attempted to interview R11, however, R11 is no longer a resident of the facility as of 05/03/2023.

Allegations: Staff verbally abused resident while in care. Staff failed to treat resident with dignity and respect.
It was reported that S1 verbally abused R11 by screaming at resident and telling resident to “Shut up”. A recording of incident was provided to Executive Director Michael Forsgern and S1 was terminated. During interview with Executive Director Michael Forsgern it was stated that the reason for S1 being terminated was because of this incident. During interviews with R1-R12, 10 out of 12 residents stated that they have never been verbally abused by staff, have not witnessed this with other residents and feel they are treated with dignity and respect. Residents also stated that they are able to use their own linens and blankets with no issues, 4 of the 5 residents interviewed today state they use their own linens.

Based on LPAs observations, interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230508083627
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2023
Section Cited
CCR
87468.1(a)(1)(3)
1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
1
2
3
4
5
6
7
A training regarding personal rights for residents will be provided to all staff prior to POC Due date. Executive Director Michael Forsgren will also provide training materials, agenda, and a log with staff signatures/initials proving they attened the training by POC due date.
8
9
10
11
12
13
14
This requirement was not met evidenced by: Based on interview with Executive Director Michael Forsgren it was stated that R11 showed the voice recording proving the alleged verbal abuse from S1 and termination of S1 was due to this incident.
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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230508083627
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: 07/21/2023
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
interviews with Executive Director Michael Forsgern, Staff # 2-4 (S2-S4) and Resident # 7-12 (R7-R11). LPA attempted to interview R11, however, R11 is no longer a resident of the facility as of 05/03/2023.

The investigation revealed the following:
Allegation: Staff failed to meet resident’s medical needs.
It was reported that the facility did not provide a good care to wound for R11. Record review of R11, interviews with Executive Director Michael Forsgern and S2-S4, and review of Skin Evaluation Guidelines it was revealed that facility does evaluations on wounds and skin breakdown upon admission and while assisting residents with their Assistance of Daily Living (ADL), if wound is observed resident’s primary physician is contacted, wound care/treatment would be provided by Home Health or by hospital staff. Upon admission 4/26/23 resident had completed treatment for wound care and was hospitalized by 5/3/23 for wound care and never returned to facility. During interviews conducted with R1-R12, 11 out of 12 residents disagree with the above allegation and stated the facility meets their medical needs.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5