198603162-6-29-2023-28-AS-WSHO-CVNL32-20230914082310

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 06/29/2023
Date Signed: 06/29/2023 12:59:12 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
06/23/2023 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230623144233

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: 74	DATE:	06/29/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joshua Oliver		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not properly assess resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Business Office Manager Joshua Oliver and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Michael Forsgren, Wellness Director Sherrie Similton and Business Office Manager Joshua Oliver. LPA collected copies of Staff and Resident rosters. LPA reviewed R1's facility file and collected copies of documents relevant to the investigation.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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-20230623144233

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: 06/29/2023

NARRATIVE

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Investigation revealed the following: Regarding allegation, Staff did not properly assess resident while in care, it is alleged that the facility performed a pseudo-assessment with no physician present, no psychiatrist present and without the presence of R1's Power of Attorney (POA) which was previously requested at least 4 times. It is also alleged that the facility did the assessment even though the administrator had issued an eviction notice and there is also a pending court case of unlawful detainer pending. Interviews conducted with Administrator and Wellness Director revealed that R1 is only POA for R1's financial matters. They stated that the assessment conducted on 06/23/23 was routine and that all residents of the facility are given an assessment as required by Title 22 regulations periodically and/or when needed. Wellness Director stated that R1 did not present any significant changes and that when the form was completed, R1 refused to sign the form. LPA reviewed documents which show that R1 has a POA and the POA assumes the fiduciary responsibilities of an agent. The document is dated 9/10/22. LPA also reviewed LI603A dated 11/23/22 and 06/23/23 and observed that there were no significant changes in R1's condition. LPA observed that the eviction issued to R1 on n12/20/22 met title 22 regulations. Based on statements gathered from interviews conducted with staff, and LPA review of documents, 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. A copy of the report was provided to Business Office Manager Joshua Oliver.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC9099 (FAS) - (06/04)

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