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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603162
Report Date: 04/19/2024
Date Signed: 04/19/2024 12:51:06 PM


Document Has Been Signed on 04/19/2024 12:51 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: 74DATE:
04/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lizbeth Acuna- Business Office ManagerTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of citing deficiencies. LPA Met with staff Lizbeth Acuna, and explained the purpose for the visit.

During an investigation conducted for a complaint dated: 3/18/22, it was discovered that Resident#1 (R1) sustained several documented falls at the facility during March 2022. Per hospice records, R1 fell at the facility on 3/01/22 and 3/20/22. Per facility incident reports obtained dated 3/03/22 and 3/20/22, facility reported to the Licensing agency that R1 sustained falls. Per R1's Physician's Report, Pre-Placement Appraisal, Needs and Services plan, and Current Appraisal, R1 was non-ambulatory and required two-person assist for transferring, but was able to propel self on her wheelchair. There was no indication that R1 was a fall risk. In the incident report and hospice notes dated 3/20/22, it was documented that R1 fell and sustained a laceration to the head that resulted in bleeding. Upon facility notifying hospice, the hospice physician ordered for R1 to be discharge from hospice and be sent to the hospital. After review of R1's records obtained, it was discovered that the facility failed to update the service plan for change of condition of R1, and not implementing interventions that led to additional falls resulting in the R1 sustaining a head laceration that required hospitalization. There was no recorded documentation from the facility or hospice indicating that the R1's Assessment/Needs and Services Plan was ever updated to reflect R1's fall risk/plan of care.

Per California Code of Regulations, Title 22, deficiencies were observed and cited during today's visit.

Exit interview was conducted and copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
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


Document Has Been Signed on 04/19/2024 12:51 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2024
Section Cited
CCR
87463(a)

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87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
This requirement was not met as evidenced by:
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Licensee will submit a written plan indicating how facility will ensure to document and update resident's plan of care any time a change in condition is observed. POC to be emailed to LPA by POC due date.
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Baased on records review, Licensee failed to update R1's appraisal/plan of care to implement fall interventions due to R1's fall history that led to R1 sustaining a head laceration, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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