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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:52:23 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
08/14/2023 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230814092308
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: 74DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Business Office Manager Lizbeth AcunaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not post CCL signs in an accessible area for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPAs) Jose Villalobos and Tyler Reyes conducted a subsequent complaint investigation visit for the allegation(s) listed above. LPAs met with Business Office Manager Lizbeth Acuna and the purpose of the visit was discussed.

Initial visit conducted on 8/16/23 consisted of the following: LPA Villalobos toured the physical plant, interviewed Staff #1-#5 (S1-S5) and collected copies of the resident and staff rosters. LPA also reviewed facility notes regarding resident falls and collected incident reports and notes.

On todays visit, LPA's interviewed residents #1-#2 (R1-R2) and toured the physical plant. 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: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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 3
Control Number 28-AS-20230814092308
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: 04/18/2024
NARRATIVE
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In regards to the allegation "Staff did not post CCL signs in an accessible area for residents" it was alleged that the facility does not post required postings from licensing and the administrators certificate. (5) of (5) Staff interviewed denied the allegation. (2) of (2) Residents interviewed could not corroborate the allegation. LPAs observed the facility to have required posting located in the hallway accessible to all residents in care. The posting observed included the personal rights form, resident council form, emergency disaster plan, CCL let us know poster, local ombudsman, facility license, and designation of facility responsibility amongst others. LPA's observed current administrator's certificate posted as well. The certificate is active. Based on interviews, file review, and observations; although the allegation may have happened or are 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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3