198603162-7-18-2023-28-AS-LHIS-CUXT5Q-20230822142556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:02:04 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
07/11/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230711153435

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	FORSGREN, MICHAEL		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 75	DATE:	07/18/2023
		UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Michael Forsgren, Administrator		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not safeguarding resident's belongings.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegation. The purpose of the visit was explained to Administrator Michael Forsgren.

The investigation consisted of the following: A physical plant tour of the interior and exterior physical plant, with focus on laundry roooms/housekeeping procedures was completed. Staff (S1- S6) and residents (R1- R8) were interviewed. File review and copies of resident (R1's) file documents: Face Sheet, Resident Appraisal, Physician Report, Appraisal/Needs and Services Plan, Admission Agreement, Laundry/Housekeeping Schedule, Housekeeping/Laundry and Caregiver Job description documents, LIc 500 Personnel Report, and resident roster were obtained. Pictures of laundry rooms were taken.

***Investigation narrative continues next page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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-20230711153435

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: 07/18/2023

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

Allegation: Staff are not safeguarding resident's belongings. It is alleged that some of the personal items are taken to be laundered and are not received back. Towels, washcloths, and a jacket were reported missing to Administration staff recently, but the issue was not addressed in a timely manner. It was reported that a gray zip-up jacket was not returned to resident (R1) with their clean laundry. Another resident had the gray zip-up jacket and it was returned to R1. According to interviews conducted, the missing towels were found, but washcloths were not. Per resident (R1), facility staff have never inventoried the resident's belongings and have never asked to report to staff when new items are purchased. NOTE: R1's missing zip-up jacket was observed in R1's room.

Six (6) staff were interviewed, of which three (3) reported knowledge of at least one incidence in which R1's laundry items were not returned the same day as required per protocol. Staff were informed several times that personal items were not safeguarded. The housekeeper staff (S7) in charge of laundering R1's laundry no longer works at the facility. Staff stated that on several occasions staff (S7) did not finish their laundry tasks; and R1's clothing was not laundered and returned the same day. Housekeeping staff are assigned to clean 4-5 resident rooms per day, which includes laundering of resident's clothing. Laundry is to be picked up, washed, dried, and delivered on the same day. A total of eight (8) residents were interviewed. Three (3) out of eight (8) residents reported that their or other resident's belongings have not been returned after being laundered. One resident reported that they received a couple pieces of clothing by mistake and to took it to the laundry room so staff can return it to the right resident.

Resident (R1's) file was reviewed. The file did not contain an inventory list of Resident Personal Property and Valuables. Administrator acknowledged that R1's file does not have an inventory list of personal property and the resident was admitted 2 years ago. During today's visit, LPA inspected the 1st and 2nd floor laundry rooms and R1's room. The 2nd floor laundry room had 2 washcloths on the shelf. Staff did not know whom they belonged to. Additionally, presently housekeeping staff are keeping track of laundry in the laundry room by writing the resident's room # on small pieces of paper they manually cut and write on, and placing the paper on top of the washer and the dryer, and then placing it on top of the clean clothes. This method may pose issues with tracking resident's belongings if the small paper is misplaced or lost.

Based on observation, record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited according to California Code of Regulations, Title 22. See LIC 9099D.

Exit interview was conducted with Administrator Michael Forsgren A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230711153435

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: 07/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/28/2023 Section Cited CCR 87217(b)	1 2 3 4 5 6 7	Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources.	1 2 3 4 5 6 7	Administrator agreed to: 1. Develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, 87217. 2. Conduct/submit proof of staff training 3. Submit R1's Inventory list of personal belongings
	8 9 10 11 12 13 14	This requirement was not met evidenced by: Based on interviews conducted, R1 has had at least one incidence in which their clothing, towels, and washcloths were not returned after being laundered; which poses a potential health and safety risk to persons in care.	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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3