198603162-10-31-2023-28-AS-JVIS-CX5R9Y-20231031125020

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603162
Report Date: 10/31/2023
Date Signed: 10/31/2023 12:50:46 PM

Document Has Been Signed on 10/31/2023 12:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	FORSGREN, MICHAEL		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 76	DATE:	10/31/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Staff Kim Mims.		TIME COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jose Villalobos conducted subsequent unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Staff Kim Mims. The following (3) of (12) CARE tool domains were completed during the inspection:

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
An activity calendar was reviewed

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is in place.
Last Emergency Drill completed 8/24/23

Residents with Special Health Needs:

There are currently (6) residents on Hospice and (25) on Home Health
Individual Service Plans and Appraisals are on file.
No residents have prohibited health conditions.
Auditory signals for emergency exits observed and operational
No bodies of water observed and fireplace is blocked and inaccessible to residents

All (12) domains have been completed as of todays visit. Per California Code of Regulations, Title 22, Deficiencies are being cited. Please see LIC 809-D page

Exit interview was conducted and a copy of this report and appeal rights were provided and discussed.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/31/2023 12:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87633(b)

Hospice Care for Terminally Ill Residents

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above a Resident #1-#3's hospice care plans were incomplete by not showing licensee/staff involvement in residents hospice care plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2023
	Plan of Correction
1 2 3 4	Facility to provide LPA with updated Hospice Care Plan's for residents #1-#3 showing facility involvement in residents care. Hospice Care Plans due by POC date provided.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

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