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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 09/19/2023
Date Signed: 09/20/2023 08:27:40 AM

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
09/22/2022 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220922092309
FACILITY NAME:WHITTIER GLEN ASSISTED LIVINGFACILITY NUMBER:
198603162
ADMINISTRATOR:ATEAIAN, KIMIAFACILITY TYPE:
740
ADDRESS:10615 JORDAN RDTELEPHONE:
(562) 943-3724
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:93CENSUS: 76DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator Michael ForsgrenTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained bruises while in care
Staff do not appropriately manage residents behavior
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation(s) above. LPA met with Administrator Michael Forsgren and the purpose of the visit was discussed.

Initial visit on 9/23/22 consisted of the following: LPA Villalobos requested a copy of Staff roster and Resident roster. LPA conducted a health and safety check of the physical plant. LPA observed the food supply. The facility was clean and in good repair and there were no observable signs of neglect, abuse or other immediate health and safety threats. LPA collected the following documents from Resident #1-#3 files: Facesheet , Physicans Report, Needs and Services Plan, Appraisal, Medication List, and Emergency Contact Sheet.

As of todays visit, LPA has interviewed Residents #2-#6 (R2-R6) and Staff #1-#5 (S1-S5). LPA unable to interview Resident #1 (R1) as they are no longer in the facility. The investigation revealed the following:
Continued on LIC 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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-20220922092309
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: 09/19/2023
NARRATIVE
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In regards to the allegation "Resident sustained bruises while in care" it was alleged that due to staff not evicting R1, R1 attacked R2 in their room leaving behind bruises. (5) of (5) Staff interviewed denied the allegation. (2) of (5) Residents interviewed stated that the facility should have evicted R1 prior to any physical violence occurring. (3) of (5) Residents interviewed were not able to corroborate the allegation.
File review shows that on 9/3/22 , R1 had gone to R2's room and assaulted them physically without warning. Local law enforcement was contacted and did arrive but R1 was not arrested. Interviews with staff show that there was not enough sufficient documentation and reasoning to evict R1 from the facility prior to this incident as doing so would break Title 22 Regulations and could be seen as an illegal eviction. There were attempts communicated to LPA regarding R1 refusing to seek physical and mental revaluations to identify whether a higher level of care was needed. Ultimately, R1 did receive an eviction notice from the facility on 9/19/22 with supportive documentation of recurring rule breaking. Based on LPA's observations and interviews; 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.

In regards to the allegation "Staff do not appropriately manage residents behavior" it was alleged that staff do not do anything regarding R1's behavior. (5) of (5) Staff interviewed denied the allegation. (3) of (5) Residents interviewed could not corroborate the allegation. Interviews with staff shows that R1 has been refusing assistance with seeing a doctor or having a re-evaluation done by staff. Due to the nature of maintaining privacy, other residents of the facility were not informed of what steps the facility was taking to ensure R1's behavior was addressed. From interviews with staff, it was believed that R1 needed to be evaluated as they may have needed a higher level of care but R1 refused. Interviews with staff also showed a plan to be vigilant of R1 in the common areas around other residents was communicated so that conflicts or disturbances to other residents involving R1 would be quickly addressed. There was no plan in place to provide 1 on 1 supervision. S1 updated LPA that Department of mental health arrived to visit R1 on 10/2/22 but they could not assist as R1 did not meet their criteria. Last needs and services plan was dated 10/3/22. R1 moved out on 10/20/22. Based on interviews and file review the facility was able to show that R1's behavior was being addressed. Based on LPA's observations and interviews; 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 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: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2