198603162-8-31-2023-28-AS-RORN-CVUL7N-20230920083034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:36:02 AM

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
08/28/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230828101736

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:	08/31/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Michael Forsgren		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff are retaliating against resident for filing complaints

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wong conducted an initial 10 days complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Administrator Michael Forsgren who allowed the entry into the facility and assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed administrator, four staff (S1-S4) and eight residents (R2-R9) and obtained copy of staff and residents roster.

The investigation revealed of the following: Allegation "Staff are retaliating against resident for filing complaints." LPA interviewed eight (8) residents and eight out of eight residents denied the allegation and reported staff are very nice and they had never experienced any retaliation from staff. The administrator is always open to talk to them about their concerns or complaints.

(LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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-20230828101736

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: 08/31/2023

NARRATIVE

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LPA interviewed staff and denied the allegation and stated they had never seen any staff retaliated against resident for filing complaints. Staff reported if resident would like to complaint and they would ask them to write it down and they will bring it to their supervisors or administrator. They would also provide the phone number for Ombudsman and Licensing.

Based on statements gathered from interviews conducted with staff and residents, 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 and appeal right was provided to Administrator Michael Forsgren.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC9099 (FAS) - (06/04)

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