198603162-7-7-2023-28-AS-TVAO-CUAL3A-20230801082333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 07/07/2023
Date Signed: 07/07/2023 12:46:34 PM

Substantiated

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
05/12/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230512150458

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	HIPOLITO, RHONWINN		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 73	DATE:	07/07/2023
		UNANNOUNCED	TIME BEGAN:	11:44 AM
MET WITH:	Michael Forsgren - Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility failed to meet reporting requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit. LPA met with administrator and explained the reason for the visit.

The investigation consisted of the following: On 5/18/23 LPA requested a copy of staff/resident roster. LPA conducted interview with administrator, wellness director, staff #3(S3), and Resident #1 (R1). Reviewed incident reports for January 2020, January 2021, requested copies of incidents occurred 6/28/22,7/02/22, 7/14/22, 7/31/22, progress notes for incidents on 7/24/22, 6/28/22, 7/31/22, facility's letterhead dated 11/23/22, and a copy of power of attorney for R1.

The investigation revealed the following: Regarding allegation - Facility failed to meet reporting requirements. It is alleged no written reports were provided to resident or responsible party for the following dates: January (unknown date) 2020 and 2021, 10/02/21, 05/12/22, 07/01/22, 07/02/22, 07/12/22.
(CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230512150458

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: 07/07/2023

NARRATIVE

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Interview with R1 revealed facility provided copies of most incident reports. However, facility did not provide an incident report for the following incidents: January 2020 to report positive cases for COVID 19. January 2021 to report bed bugs in resident’s room. Administrator submits incident reports to the department and it is not aware of the reason facility failed to submit incident report for incident on 7/14/22. Administrator was not employ with the facility at that time. During file review, LPA observed facility provided R1 and R1’s representatives a copy of R1’s file on 11/23/22 containing letter of response, billing records, and health record. Health notes kept by the facility were provided on 11/23/22 for the following dates: 10/2/21 6/28/22,7/24/22,7/26/22, 7/29/22,7/31/22.

Facility did not submit incident reports to report any COVID cases in January 2020 because there were no positive cases. Facility did not submit any incident reports in the month of January 2021 related to bed bugs because there was no proof the facility had bed bugs. LPA reviewed pest control invoices and discovered the company treated room #229, but there was no documentation that the room had bed bugs. LPA reviewed incident reports submitted to the department and discovered no incident reports were submitted to the department for 5/12/22, 7/2/22 or 7/14/22. Facility provided copies of incident reports to LPA during the initial complaint investigation visit conducted on 5/18/23 for incidents on 7/2/22 and 7/14/22. A transmission copy for incident on 7/2/22 was provided to LPA during today's visit to confirm incident was faxed to the department. Facility failed to report incidents occurred on 7/14/22 to the department and failed to provide written notification to R1 and responsible party. There are no records to indicate an incident occurred on 5/12/22.

Based on document review conducted, the preponderance of evidence standard has been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is SUBSTANTIATED.

Exit interview was conducted with Administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230512150458

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: 07/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 07/21/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 Reporting Requirements: (a) Each licensee shall furnish...: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will request in-service training for self and wellness director from corporate and will provide a written notice to responsible party and R1 of any incident. Administrator will provided a copy of in-service to the department by POC due date 7/21/23.
	8 9 10 11 12 13 14	Based on document review licensee failed to report incidents occured on 7/14/22 to CCLD and resident's responsible party which poses a potential personal right, health, or safety risk to the 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.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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