198603162-3-21-2023-28-AS-RORN-CVDMK7-20230905094014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 03/21/2023
Date Signed: 03/21/2023 04:26:32 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
02/09/2023 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230209174510

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	ATEAIAN, KIMIA		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 65	DATE:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Operations Manager Michael Forsgren		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff are not keeping accurate accounting records for residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent visit for the allegation above. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed.

Initial visit on 2/14/23 consisted of: LPA interviewing Staff #1-#4 (S1-S4) and Resident #1-2 (R1-R2). LPA toured the physical plant of the facility and observed the food supply. LPA collected a copy of the staff and resident roster. LPA collected documents related Resident #1's (R1) File such as the facesheet, needs and services plan, medication record, and any related facility notes.

On Todays visit LPA interviewed Staff #5 (S5), Residents #3-5 (R3-R5) and reviewed R1's facility ledger account and balance statements. Staff #6 (S6) no longer works in the facility and was unavailable for interview.

The investigation revealed: In regards to the allegation "Staff are not keeping accurate accounting records for residents in care" it was alleged that the facility does not have an accurate accounting record for R1...
((CONTINUED ON LIC 9099-C))

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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
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
02/09/2023 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230209174510

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	ATEAIAN, KIMIA		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS:	DATE:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Operations Manager Michael Forsgren		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff retaliate against individuals who cooperates with compliant investigations

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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-20230209174510

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: 03/21/2023

NARRATIVE

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Regarding the allegation "Staff retaliate against individuals who cooperates with compliant investigations" it was alleged that the facility staff will intimidate residents to not complain and deny incidents in the facility. (5) of (5) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Interviews with residents do not show that staff intimidate residents in any way. LPA was not provided with specific example of how staff intimidate the residents of the facility. All staff interviewed denied that they would intimidate residents or tell them to not complain or keep quiet about incidents in the facility. Interviews with staff state that they encourage residents to speak out in regards to any problems they are having in the facility. Although the allegations may have happened or are 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 the report was provided

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20230209174510

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: 03/21/2023

NARRATIVE

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(5) of (5) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Interviews showed that R1 received a rate increase for level of care after being provided a 60 day notice from the facility. Interviews also stated that R1 continues to pay the monthly amount before the increase to the facility took place even though they were provided the 60 day notice. The account files for R1 reviewed show that the increase was applied 2 months after the notice was provided. The documents do show the change in total amount due by R1 monthly and what the accurate current balance is. In the account file reviewed, there is a charge of $7.40 applied on 8/31/21 and $203.23 applied on 10/20/21. These charges are identified only as "care charges" or "ancillary charges". Interviews could not detail the reason for these charges which are separate from level of care and room and board charges. Interviews stated it is the Business Manager who manages the account files and will log and file the receipts for the charges on any residents account; however, the facility files did not have receipts of documentation as to what these charges are for at the time of the visit. S6 was the Business Manager at the time and no longer works in the facility. Based on interviews and files reviewed, the facility did fail to maintain accurate accounting records for R1's file due to not having accurate documentation of certain charges made to R1 as stated above. The preponderance of evidence standard has been met, therefore the allegation is 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 discussed and provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230209174510

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: 03/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/31/2023 Section Cited CCR 87213	1 2 3 4 5 6 7	87213.Finances.The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that...; shall maintain adequate financial records. This was not met as evidenced by:	1 2 3 4 5 6 7	Facility to provide in service training on proper documentation of charges or credits provided to residents in care by POC due date.
	8 9 10 11 12 13 14	LPA reviewed R1 facility ledger statements and observed charges on R1's account that the facility was unable to provide a reason for. 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 Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5