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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603162
Report Date: 10/27/2023
Date Signed: 10/27/2023 03:11:37 PM


Document Has Been Signed on 10/27/2023 03:11 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 LIVINGFACILITY NUMBER:
198603162
ADMINISTRATOR:FORSGREN, MICHAELFACILITY TYPE:
740
ADDRESS:10615 JORDAN RDTELEPHONE:
(562) 943-3724
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:93CENSUS: 76DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff Kim Mims.TIME COMPLETED:
03:10 PM
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Licensing Program Analysts (LPA) Jose Villalobos conducted an 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 (9) of (12) CARE tool domains were completed during the inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

Operational Requirements:
  • A current Plan of Operation was reviewed. The Infection Control Plan and Dementia Care Plan observed.
  • A Hospice Waiver for 6 is approved.
  • A fire clearance for 93 residents of which (93) may be non ambulatory; 0 may be bedridden.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place.

Physical Plant/Environment Safety:
  • The physical plant consists of a two story building structure that contains the following: First floor consists of resident rooms with individual bathrooms, 1 living room, Dining Rooms, courtyard, 3 offices, medication room, kitchen, and laundry area. The facility second floor consists of the following: resident bedrooms with individual bathrooms, laundry room, outdoor porch seating area, and Activity room.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents....

Continued on LIC 809-C
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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
VISIT DATE: 10/27/2023
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  • On 8/24/23, The sprinkler system, alarms, fire connections, and Fire panel were inspected. The facility has fully charged fire extinguishers.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. LPA tested rooms #109 , #118 , #121, #128, #125, #206, #215. #218, #221, #226, and #232. Staffing:
  • A total of 42 staff members provide care and supervision to the clients.
Personnel Records/Staff Training:
  • Administrator on record is not current. Documents are pending Department review.
  • Staff have criminal background clearance and training.
  • Seven (7) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training was observed.
Resident Records/Incident Reports:
  • A total of seven (8) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.
Resident Rights-Information
  • RCFE complaint poster and other required postings were observed.
  • Training on personal rights observed
Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
  • Physician orders for modified diets are on file.
  • Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:
  • Seven (7) centrally stored resident medications were reviewed.
  • Medical and dental transportation is provided.

Due to time constraints, LPA is unable to complete the annual inspection and will return at a later time to completed the remaining (3) of (12) Domains and conduct remaining interviews.

Per California Code of Regulations, Title 22, NO deficiencies were cited. Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2