198603162-3-20-2024-28-AS-DSIS-D5WUJZ-20240604153821

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603162
Report Date: 03/20/2024
Date Signed: 03/20/2024 01:32:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/15/2024 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240315094335

FACILITY NAME:	WHITTIER GLEN ASSISTED LIVING		FACILITY NUMBER:	198603162
ADMINISTRATOR:	FORSGREN, MICHAEL		FACILITY TYPE:	740
ADDRESS:	10615 JORDAN RD		TELEPHONE:	(562) 943-3724
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	93	CENSUS: 70	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kathleen McDonald (Katie)		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Resident possibly has possession of a firearm.
Resident verbally attacked another resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wong conducted an initial "10 days" complaint visit and ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 Michelle Bascom (Receptionist) who allowed entry into the facility and was later met by Wellness Director Kathleen McDonald (Katie) who assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed eight (8) staff (S1-S8) in the facility and sevevn residents (R2-R8) in the facility and administartor via telephone. LPA obtained the copy of the resident and staff roster and R1 and R2 face sheet, physician report and needs and service plan and the copy of the staff in serve training about de-escalation.

See LIC 9099C for continuation

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240315094335

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: WHITTIER GLEN ASSISTED LIVING	FACILITY NUMBER: 198603162
	VISIT DATE: 03/20/2024

NARRATIVE

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The investigation revealed of the following: Allegation#1 "Resident possibly has possession of a firearm." It's alleged that a man went into R2's room for less than a minute and left the building and possibly dropped off a gun in R2's room as R2 was asking for a gun a couple weeks ago in the facility. LPA interviewed seven (7) residents and five out of seven residents denied the allegation. They never heard and seen any resident has possession of a firearm. LPA interviewed staff and all denied the allegation. They never heard and see any resident has possession of a firearm. LPA also toured the room of R2 and did not observe any possession of a firearm.

Allegation#2 "Resident verbally attacked another resident in care. " It's alleged that R2 was verbally attacked R1 and threatened R1 and yelled at R1. LPA interviewed residents and reported R1 and R2 always argued in the facility for unknown reason but four out of seven residents denied seeing them hitting each other. Residents indicated staff interfered immediately and separated both residents and asked residents to calm down when two residents started arguing or verbally attacking each other. LPA interviewed staff and reported R1 and R2 do not like each other for some reasons. Staff always kept an eye on them. Staff stated that they usually ensure R1 and R2 were not in the same location or area. Regarding the altercation between R1 and R2 few weeks ago, the staff were in the kitchen prepared and served food and it was happened so fast, therefore no staff was not around while incident happened. Both R1 and R2 resolved themselves at the end and no one was getting hurt. Once the staff found out, staff immediately evacuated the dining area to prevent any other residents were involved in the incident. The administrator reported usually if something happened between two residents, staff would always de-escalate the situation and separate the residents immediately. They would also call police or paramedic if needed.

Based on the interviews were conducted with staff and residents, 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 allegations are Unsubstantiated.

Exit interview was conducted. A copy of the report was issued.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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