198603162-9-5-2023-28-AS-RORN-CX5VC7-20231031161839

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 09/05/2023
Date Signed: 09/05/2023 05:11:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/16/2023 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230216131906

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	ATEAIAN, KIMIA		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 75	DATE:	09/05/2023
		UNANNOUNCED	TIME BEGAN:	02:01 PM
MET WITH:	Administrator Michael Forsgren		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff does not provide a safe environment for residents while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation(s) above. LPA met with Administrator Michael Forsgren and the purpose of the visit was discussed.

Initial visit was conducted on 2/22/23 and consisted of the following: LPA interviewed Staff #1-#3 (S1-S3) and Residents #2-#3 (R2-R3) and toured the physical plant. LPA unable to interview Resident #1 (R1) as R1 is no longer in the facility. LPA collected documents from the facility from R1's file as well as a copy of the staff and resident roster.

As of todays visit, LPA Villalobos interviewed Staff #4-#5 (S4-S5) and Residents #2-#6 (R2-R6). LPA was unable to interview R1 as R1 is no longer in the facility. The investigation revealed the following:

Continue on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

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-20230216131906

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/05/2023

NARRATIVE

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In regards to the allegation "Facility staff does not provide a safe environment for residents while in care." it was alleged that Residents expressed not trusting facility's actions to maintain them safe from R1. (5) of (5) Staff interviewed denied the allegation. (2) of (5) Residents interviewed stated they did not feel safe around R1 and were unsure what the staff were doing in order to keep them safe. Interviews stated that R1 was a resident who did have multiple incidents with their behavior in the facility. All incidents were reported and responsible parties notified as LPA reviewed incident reports on file. Local police were called for incident of R1 attacking R2 but no arrests were made and no charges were pressed. Interviews with staff state that there were multiple attempts to have R1 see a psychiatrist and doctor for their behavior but R1 refused. Interviews also stated that due to keeping R1's information confidential and allowing for their privacy, residents of the facility were not told outright what was being done regarding R1's behavior. Residents were encouraged to come to staff with any issues or problems so that there would be no altercations. R1 was served an eviction notice by the facility on 9/19/22 and left the facility on 10/20/22. This shows the facility was aware and proactive regarding R1's behavior and how it affected the other residents. Based on the interviews conducted, observations and files reviewed, 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 was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

LIC9099 (FAS) - (06/04)

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