197602925-4-15-2022-28-AS-LHIS-CEHGKK-20220517052448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602925
Report Date: 04/15/2022
Date Signed: 04/15/2022 12:53:35 PM

Unsubstantiated

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
04/08/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220408164558

FACILITY NAME:	ARBOR VISTA		FACILITY NUMBER:	197602925
ADMINISTRATOR:	COMMODORE, KIM		FACILITY TYPE:	740
ADDRESS:	811 E WASHINGTON BLVD		TELEPHONE:	(626) 797-7296
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	69	CENSUS: 49	DATE:	04/15/2022
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Kim Commodore, Administrator		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Verbal abuse

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit regarding the above allegation and delivered findings. The purpose of the visit was explained to Administrator Kim Commodore.

The investigation consisted of: On 4/12/22, LPA Galarza and Associate Governmental Program Analyst (AGPA) Michael Moriel conducted a physical plant tour, interviewed staff (S1-S5), and resident (R1). The following documents were obtained pertaining to R1: Face Sheet, Physician Report, ALW ISP, Appraisal Needs and Services Plan, incident reports, SNF & hospital discharge documents, LIC 500 Personnel Report, and resident roster. Durable Power of Attorney (DPOA) and Home Health staff were interviewed. During today's visit, residents (R2- R9) were interviewed.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

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-20220408164558

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: ARBOR VISTA	FACILITY NUMBER: 197602925
	VISIT DATE: 04/15/2022

NARRATIVE

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Allegation: "Verbal Abuse". It is alleged that on April 4, 2022 ,caregiver staff (S1) became upset and was yelling in front of resident (R1), visitor, and Administrator when questioned about a toe injury that was observed in resident (R1's) left toe. It is also alleged that the Administrator also became upset and raised its' voice, as it had not been made aware of the toe injury. The resident sustained a minor trauma wound on the left toe (picture obtained). Resident (R1) stated that staff (S1) accidentally stepped on the toe during wheelchair to the bed transfer. The resident stated that it did not realize the toe was injured until April 4, 2022, and did not report it staff (S1) or Administrator because it loves and respects staff (S1). Resident (R1) denied being verbally abused by staff (S1) and/or any other staff. Five (5) out of five (5) staff interviewed denied the allegation. Staff (S1) denied verbal abuse and yelling at resident, but did admit that it always talks loud, especially towards resident (R1) because the resident is hard of hearing and sometimes does not have its' hearing aids on. Nine (9) out of nine (9) residents interviewed denied verbal abuse by staff (S1) or other staff. On 4/12/22, LPA interviewed resident (R1) and confirmed that R1 has severe hearing loss, wears hearing aids, and must be talked to in a loud voice. Resident (R1) stated she is very happy and grateful for the care that staff (S1) provides. Resident (R1's) Durable Power of Attorney stated R1 is treated well by staff (S1), and confirmed R1 is hard of hearing. Therefore, staff must speak to the resident in a loud tone. Based on interviews conducted and document review, there was not enough supportive evidence to concur with the reported allegation.

Although the allegation may have happened or is valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore all the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Administrator Kim Commodore. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022

LIC9099 (FAS) - (06/04)

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