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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602334
Report Date: 01/29/2021
Date Signed: 01/30/2021 07:18:12 AM



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
09/02/2020 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200902083934
FACILITY NAME:PASADENA HIGHLANDSFACILITY NUMBER:
197602334
ADMINISTRATOR:KAY LYNN CANOFACILITY TYPE:
740
ADDRESS:1575 EAST WASHINGTON BOULVARDTELEPHONE:
(626) 791-1981
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:256CENSUS: 145DATE:
01/29/2021
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Kay Cano TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff leave resident soaked in urine for extended periods of time
Facility staff switched resident's medication without resident's consent
Facility staff failed to give resident medication as prescribed
Facility staff failed to treat resident with dignity and respect
Facility staff failed to clean resident's laundry and room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint investigation to deliver findings on the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with facility staff Kay Cano

The investigation consisted of the following: the initial complaint visit was conducted on 09/08/2020, LPA interviewed Executive Director and Health & Wellness Director. LPA requested documents pertaining to resident (R1) including Identification and Emergency Contact/face sheet, Admission agreement, physician report, resident's appraisal and needs and service plan (Care plan), medication administration records (MARs) and physician order for the medication. LPA also interviewed residents (R2-R14) and staff (S3-S8) on October 2020.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
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 3
Control Number 28-AS-20200902083934
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: PASADENA HIGHLANDS
FACILITY NUMBER: 197602334
VISIT DATE: 01/29/2021
NARRATIVE
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The investigation revealed of the following: Allegation#1 “Facility staff leave resident soaked in urine for extended period of time.” All residents denied the allegation. They both reported that they never soaked in urine for a long period of time. LPA interviewed the staff and they all denied the allegation and reported they would do the hourly check for the residents who are in bedridden or not able to communicate and make sure they are dry and comfortable. For the residents can communicate their needs, the staff would assist the resident to go to the bathroom or change diaper if they needed. For Resident#1 (R1), the staff reported that staff was going to change her diaper but R1 told the staff that she was not ready yet, therefore R1 was soaked in urine for couple minutes only but not extended period of time.

Allegation#2 “Facility staff switched resident’s medication without resident’s consent.” LPA interviewed residents and they all denied the allegation and reported that it never happened on them and never heard that happened in the facility too. LPA interviewed the staff and they all reported they always follow resident’s doctor order for the medication. If medication needs to be switched and the facility staff need to contact residents’ doctor and get the approval and discuss with the family and resident and finalized. The facility staff reported that they do not have the power to switch resident’s medication without doctor’s approval.

Allegation#3 “Facility staff failed to give resident medication as prescribed.” LPA interview residents and they all denied the allegation and reported it never happened and the staff always give the correct medication to them and dispense the medication on time. LPA interviewed staff and denied the allegation and reported they always follow the doctor’s list of the medication for all residents. Staff stated that sometimes R1 likes to pick and choose her own medication but staff never failed to give resident medication as prescribed. .

Allegation#4 “Facility staff failed to treat resident with dignity and respect.” LPA interviewed residents and all reported staff are nice, great, respectful and professional. LPA Interviewed staff and all denied they would treat resident without respect and dignity and they never heard any staff being mean to the residents.
Allegation#5 “Facility staff failed to clean resident’s laundry and room.” LPA interviewed residents and they all denied the allegation and reported the staff did a good job cleaning their room and they do their laundry once a week or on the specific schedule date. Staff would never forget about it and provide a very wonderful service for them. For staff, they all denied the allegation and reported due to Covid-19, R1 needed to be isolated for 14 days when she first moved to the facility. While R1 was quarantined /isolated, the staff supposed not do any laundry and house cleaning for R1, but the staff still worked it out for her although it was delayed and R1 was very upset. They staff reported that they never found R1's room is unclean and R1's room is always clean and neat.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200902083934
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: PASADENA HIGHLANDS
FACILITY NUMBER: 197602334
VISIT DATE: 01/29/2021
NARRATIVE
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Based on statements and interviews conducted with staff and clients and there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

A telephonic exit interview was conducted with facility staff Kay Cano. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3