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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 04/30/2024
Date Signed: 04/30/2024 03:27:08 PM

Substantiated


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: 75DATE:
04/30/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Business Office Manager Lizbeth AcunaTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff are not logging incidents with residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPAs) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation(s) listed above. LPA met with Business Office Manager Lizbeth Acuna and the purpose of the visit was discussed.

Previous visits 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. LPA has also collected list of residents who receive staff assistance with showering and toileting needs. LPA interviewed residents #1-#2 (R1-R2) and toured the physical plant. On todays visit, LPA has interviewed Residents #3-10 (R3-R10) and Staff #6-7 (S6 and S7).

The investigation revealed the following:

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
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 6
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: 75DATE:
04/30/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Business Office Manager Lizbeth AcunaTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Residents have fallen multiple times due to staff neglect
Staff are not meeting residents needs
Staff left residents in soiled diapers for an extended period of time
Staff are not meeting residents showering needs
Staff are not providing a secure way to pay rent
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation(s) listed above. LPA met with Business Office Manager Lizbeth Acuna and the purpose of the visit was discussed.

Previous visits 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. LPA has also collected list of residents who receive staff assistance with showering and toileting needs. LPA's interviewed residents #1-#2 (R1-R2) and toured the physical plant. On todays visit, LPA has interviewed Residents #3-10 (R3-R10) and Staff #6-7 (S6 and S7).

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: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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: 04/30/2024
NARRATIVE
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In regards to the allegation "Residents have fallen multiple times due to staff neglect" it was alleged that residents were falling in the facility due to staff not addressing issues with cracks on the sidewalks. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews with residents and staff noted that residents fall due to other reasons not related to the cracks on the concrete sidewalks. LPA received photos of cracks on sidewalks around the facility. Residents interviewed stated to have no issues with the cracks as they are not large or they can go around them if needed. LPA observed the cracks around the facility. One crack was large but was in an area used for the facilities dumpsters and not a resident walkway. No documentation or interviews showed that residents fell due to the this crack. 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.

In regards to the allegation "Staff are not meeting residents needs" it is alleged that there is not a sufficient amount of staff to meet resident needs. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Staff interviewed stated they are able to meet the residents needs everyday. Residents interviewed stated they have their needs met and are not aware of which other residents may not be having their needs met. LPA observed sufficient staffing during the 3 separate visits conducted. 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.

In regards to the allegation "Staff left residents in soiled diapers for an extended period of time" it is alleged that residents are left in wet and soiled diapers for hours. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Residents interviewed who receive assistance with diaper changes stated that staff check in and change them regularly. The residents are also able to contact staff with the call system to request to be changed when needed. LPA was not provided with specific names or times when a resident was left in soiled diapers for extended periods of time. Staff stated to work together to make sure residents are changed and checked on regularly throughout the day. There is a caregiver assigned to each floor throughout the day as med tech staff also assist the residents. LPA observed staff throughout the visit to be assisting residents in need. 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.

Continued on LIC 9099-C
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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: 04/30/2024
NARRATIVE
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In regards to the allegation "Staff are not meeting residents showering needs" it is alleged that staff are conducting showers timely for residents who need that assistance. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Staff interviewed detailed that there is a computer/phone application system that provides the daily assignments on residents who needs showering assistance. Staff interviewed stated they complete the assignments without missing and have not missed any residents showers. Residents interviewed who receive assistance in showers from staff did not have any complaints. There were no specific resident names or times about a resident not being given a shower when needed. 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.

In regards to the allegation "Staff are not providing a secure way to pay rent" it is alleged that the facility does not provide the residents a secure way to pay their rent. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews with staff stated that residents are able to pay their rent via direct deposits, cash or checks. Whichever method is most comfortable to them. There is also a locked safe area where residents may deposit their payment if they do not want to hand it personally which is always in sight of staff. Interviews stated no one uses it as most people pay direct deposit or hand the administrator or business office manager the check in hand. Many residents will have their responsible parties, usually a family member, make the payments for them as well. Interviews with residents does not show that there is an issue with the methods in which they can pay their rent. Residents interviewed did not express any issue in the security of making their payments. 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.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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: 04/30/2024
NARRATIVE
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In regards to the allegation "Staff are not logging incidents with residents" it is alleged that the facility does not properly record incidents involving resident incidents and hospitalization's. (7) of (7) Staff interviewed denied the allegation. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews with staff shows that there is a incident/accident report that is filled out by staff whenever an incident occurs in the facility involving the residents. Depending on the situation, the incident is then reported to Licensing , a residents physician, and the residents responsible party. LPA reviewed the facilities internal incident reports and attempted to match them with the incident reports received by Licensing. LPA observed that there are facility incident reports that fall under the reporting requirements set by the department that were not followed. There is an facility incident report dated 6/1/23 of a resident being hospitalized that was not submitted to licensing. There is another facility incident report of a resident threatening another resident dated 12/6/22 not reported to Licensing. This shows the facility failed to properly record incidents in the facility by not following reporting requirements. Based on LPAs interviews conducted, files reviewed, and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted and a copy of this report was provided. Appeal rights provided and discussed
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2024
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1) 87211 Reporting Requirements: (a) Each licensee shall furnish..: (1)A written report shall be submitted to the licensing agency... within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident..
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Facility will conduct in-service training for staff and create incident reports to file from the previous mentioned dates. Administrator will provide a copy of in-service training along with names of participants to the department by POC due date provided.
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This requirement is not met as evidence by:

LPA observed facility reports dated 6/1/23 and 12/6/22 met the above requirement but were not reported to licensing which poses a potential health and safety risk to the 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: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6