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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:24:11 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
07/21/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230721141211
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: 70DATE:
01/11/2024
UNANNOUNCEDTIME BEGAN:
02:21 PM
MET WITH: Busniess/ HR Manager Lizbeth AcunaTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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9
Staff is denying resident's representative the right to represent resident in matters pertaining to the resident's residency at the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Busniess/ HR Manager Lizbeth Acuna and the purpose of the visit was discussed.

Initial visit on 7/28/23 consisted of the following: LPA requested a copy of staff/resident roster. Conducted interview with Staff #1-#4 (S1-S4) and Resident #2. LPA reviewed and collected documents related to Resident #1's file such as documentation of power of attorney, identificaiton and emergency sheet, physician's report, and, admission agreement.

As of todays visit, LPA has interviewed staff #5-#6 (S5-S6) and residents #3-#6 (R3-R6). R1 was not available for interview. Staff #7 (S7) no longer works in the facility and was unavailable for interview. The investigation revealed the following:

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20230721141211
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: 01/11/2024
NARRATIVE
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In regards to the allegation "Staff is denying resident's representative the right to represent resident in matters pertaining to the resident's residency at the facility." it was alleged that the facility did not allow R1's representative to represent R1 regarding their needs and services received at the facility. (6) of (6) Staff interviewed denied the allegations. (5) of (5) residents interviewed could not corroborate the allegation. Interviews with staff show that R1 had their needs met for their duration of their stay in the facility. R1 left the facility in July 2023. Interviews show that there had been an ongoing dispute that started in November 2021 between R1's relative and the facility regarding a rent increase. R1's relative became R1's responsible party and Power of Attorney on 9/10/2022. R1 was self responsible up until that point. Interviews conducted also show that administrators of the facility and representatives of the corporation were in contact with R1's relative from the start of the dispute up until the day that R1 left the facility. LPA was not provided proof that the facility did not allow R1's power of attorney to represent them during the time they were R1's representative. Based on observation, interviews and file review; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Exit Interview conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2