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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603162
Report Date: 09/19/2023
Date Signed: 09/20/2023 08:15:19 AM

Document Has Been Signed on 09/20/2023 08:15 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:FORSGREN, MICHAELFACILITY TYPE:
740
ADDRESS:10615 JORDAN RDTELEPHONE:
(562) 943-3724
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 93CENSUS: 76DATE:
09/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Administrator Michael Forsgren TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced case management visit to review and collect documentation of rent increases provided to residents of the facility back in August of 2022. LPA met with Administrator Michael Forsgren and a copy of this report was provided.

On todays visit LPA Villalobos reviewed documentation of the resident census on August 2022 as well as the charges for rent and care per resident. LPA collected the Resident Admission Agreement for (30) of the (54) residents listed on the census. LPA observed that (15) residents were provided a notice of an adjustment to their monthly care fee's to reflect the current rate of the facility. The documents for these (15) residents make up part of the total (30) that were collected during the visit. LPA interviewed Staff #1 who informed LPA that the letters of increase were provided to residents receiving Level 1 care who were not being charged the facilities current rate of $525 for that level of care. The increase to these (15) residents was not due to any change in their level of care or basic rent. LPA informed the facility to provide Licensing with the remaining (24) resident admission agreements by 9/21/23 close of business for licensing to review.

Exit Interview conducted and copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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