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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603162
Report Date: 08/25/2022
Date Signed: 08/26/2022 08:07:58 AM

Document Has Been Signed on 08/26/2022 08:07 AM - 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:ATEAIAN, KIMIAFACILITY TYPE:
740
ADDRESS:10615 JORDAN RDTELEPHONE:
(562) 943-3724
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 93CENSUS: 50DATE:
08/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Administrator Pamela Junge TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos conducted a case management visit after discovering deficiencies during a complaint investigation for control number: 28-AS-20220720132522.

Regarding Resident #1(R1), interviews and documentation shows that the facility retained a resident who's primary need for care and supervision results from either: an ongoing behavior, caused by a mental disorder, that would upset the general resident group.

California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D.

Exit Interview conducted with Administrator Pamela Junge. A copy of this report along with Appeal Rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2022
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 08/26/2022 08:07 AM - It Cannot Be Edited


Created By: Jose Villalobos On 08/25/2022 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/09/2022
Section Cited
CCR
87455(c)(3)(A)

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87455 Acceptance and Retention Limitations c) No resident shall be accepted or retained if any of the following apply: (3) The resident's primary need for care and supervision results from either:(A)An ongoing behavior, caused by a mental disorder, that would upset the general resident group;
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Administrator to reach out to Department of Mental health (DMH) for assistance regarding R1. Faciltiy to reassess R1 to review proper placement. Administrator will send letter to LPA of contacts made to DMH and reassessment by POC Due Date.
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This what not met as evidenced by:
R1's primary diagnoses led to an ongoing behavior of shouting at yelling at staff and residents that upsets the general resident group.

This poses a potential health and safety risk to residents in care and supervision.
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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 Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
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