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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 08/11/2023
Date Signed: 08/11/2023 11:55:16 AM

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
06/29/2022 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20220629141124
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: 75DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Business Officer Manager Joshua OliverTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Resident sustained a bruise while in care
Resident inappropriately touched other residents
Facility is not maintained clean and sanitary
INVESTIGATION FINDINGS:
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On 08/11/23 at 11:10 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent 10-day complaint visit, to deliver findings. LPA met with Business Office Manager Joshua Oliver and explained the reason for the visit. The allegation was also investigated by Jose Santana from the investigative branch.

During the initial visit on 6/30/2022, LPA Baptiste requested a copy of Staff roster and Resident roster. LPA Baptiste conducted a health and safety check which included a tour of the resident bedrooms, bathroom, dining room, laundry, activities room, outdoor patio, kitchen, and food supply. LPA observed that there was at least a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. The facility was clean and in good repair and there were no observable signs of neglect, abuse or other immediate health and safety threats.

Report continued on 9099c
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
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
Control Number 28-AS-20220629141124
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: 08/11/2023
NARRATIVE
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During the subsequent visit on 11/07/2022, LPA Baptiste obtained a copy of Staff roster, Resident roster, R1 unusual incident report dated 4/01/22 and 6/12/22, 9099 dated 4/14/2022, R2 admissions agreement, R2 Identification and emergency information, physicians report, and R2 appraisal. LPA Baptiste conducted a tour of the resident bedrooms/bathrooms in rooms 109,121,124,208,226,230. LPA interviewed Operations manager and Staff # S1 and S2. LPA interviewed service coordinator(S3) and residents# R3 through R8.


The investigation reveals the following: Regarding " Resident sustained a bruise while in care.", This allegation was investigated on 4/14/2023 and was unsubstantiated. According to the investigation staff noticed residents were intoxicated and R1 had a bump on their forehead. Staff called paramedics and assisted R1 and R14. Interviews do not show lack of supervision as residents were in private behind closed doors. There are no existing laws or regulations that prevent residents from eating or drinking what they please. R1 stated to not have been made to do something against their will. Review of R1 and R14's file does not show limitation on what they are able to eat or drink. R1's file does not show that they need a certain amount of supervision from staff. Based on the interviews conducted, observations and files reviewed, 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. Please see complaint # 28-AS-20220407162336 for further information.

The investigation reveals the following: Regarding “Facility is not maintained clean and sanitary.", it is alleged that the resident’s bedrooms are unsanitary and residents shower contains mildew. During the tour of the facility, LPA did not observe mildew in the resident bathrooms nor any unsanitary living conditions. The Operations Manager denied the allegation stating the rooms are cleaned on a weekly basis. 3 out of 3 staff denied the allegation stating they have not seen mildew in the facility. 6 out of 6 residents interviewed denied the allegations stating their bedrooms and bathrooms are cleaned every day.

The investigation reveals the following: regarding " Resident inappropriately touched other residents.", it is alleged that R3 inappropriately touched residents. Per IB’s investigation there are no witnesses who saw R3 attempt to grab resident R1 in the facility elevator. Since R3 denied doing so, we do not have any concrete basis to conclude it occurred. Regarding the incident between R2 and R3, per IB investigator R2 stated they consented to the sexual encounters with R3.

Based on LPA's interviews, investigation revealed: 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 conducted with Business Office Manager Joshua Oliver and a copy of this record provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 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
06/29/2022 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20220629141124

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: 75DATE:
08/11/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Administrator Michael ForsgrenTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Staff did not properly supervise a resident in care
INVESTIGATION FINDINGS:
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On 8/11/2023 at 11:10 a.m, Licensing Program Analyst (LPA) Jewel Baptiste made an unannounced visit to the facility and was greeted by Business Office Manager Joshua Oliverand explained the reason for the visit.
The purpose of the visit is to deliver the findings from the original complaint dated 6/22/2022.
An initial Health and Safety check visit was conducted on 6/30/2022.

An investigation was conducted by the Investigations Branch (IB) from the Department of Social Services and completed 9/21/2022 and included the following: Obtaining and reviewing documents from the facility, interviews with current staff members and former staff members, family members and medical providers. IB also conducted interviews with Resident#1 (R1) and Resident #2 (R2), Resident #9 through Resident #13, medical records and records from Whittier P.D.

Report continued on 9099c

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220629141124
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: 08/11/2023
NARRATIVE
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The investigation reveals the following: Regarding the allegation “Staff did not properly supervise a resident in care”, During IB’s investigation Resident #2 was found to have had several sexual encounters with Resident #3. Resident #3 was noted to have touched Resident #2 in a sexual manner on at least three separate occasions. These incidents were separately and individually reported to the facility receptionist by a facility staff member, a Resident, and a Resident’s Responsible Party. Resident#2 stated they consented to the encounters with R#3. Due to Resident #2 medical diagnosis Resident #2 may lack the capacity to give consent. However, even if Resident #2 had the capacity to consent, the facility was still negligent as nothing was done to verify resident #2 capacity. The facility did not address the first two incidents between Resident #2 and Resident #3 for the following reasons: Either Staff #4 failed to report the incidents to the Administrator, or The Administrator decided not to investigate the matter. IB Substantiated on Neglect/Lack of supervision due to the facility failing to establish Resident#2 capacity for consent.

Based on observation, interviews and file review, the preponderance of evidence standard has been met, therefore, the above allegations is found to be SUBSTANTIATED. Exit Interview Conducted with Administrator Michael Forsgren / Appeal Rights Provided / A Copy of the Report Issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220629141124
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: 08/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1 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.
This requirement is not met as evidenced by;
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The administrator will ensure the personal right of residents in all facilities The administrator will retrain staff regarding the personal right and how to handle residents personal relationships. The facility will send the staff training log to LPA by POC due date
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Based on observation, interviews conducted and file review it was revealed that the facility did not ensure Resident #2 had the capacity to establish consent for a sexual relationship when they were notified, which poses an immediate health, safety, or personal rights risk to persons in care.
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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 HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5