197602925-7-6-2022-28-AS-MVAO-CJFUQW-20220920154750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602925
Report Date: 07/06/2022
Date Signed: 07/06/2022 02:32:07 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
06/30/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220630091412

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:	07/06/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Kim Commodore, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident is being illegally evicted from the facility.
Facility did not ensure that resident was receiving their medication while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced complaint visit regarding the above allegations. LPA met with Staff, Willa Mae, and explained the reason for the visit. Administrator, Kim Commodore, arrived at 10:40 a.m. to assist with the visit.

The investigation consisted of the following:
LPA obtained copies of Staff roster, Resident Roster, and documents for Resident #1. LPA interviewed the Administrator, 2 Staff, and 5 Residents. During the visit today, LPA also reviewed the medication log for 5 residents.

The investigation revealed the following:
Allegation – Resident is being illegally evicted from the facility.
Administrator Commodore denied serving an eviction notice to Resident #1 (R-1).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

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-20220630091412

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: 07/06/2022

NARRATIVE

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She stated that although R-1 has not been paying the rent in full, she has not given any eviction letter. The 2 Staff interviewed stated that there were no eviction letters given to any residents. LPA interviewed R-1 who stated an eviction notice was given about 2 weeks ago and cannot recall if it was signed. R-1 was unable to provide a copy of the notice for verification. LPA interviewed R-1’s family member who is unaware of any eviction letter given to R-1 and is seeking for a place with higher level of care for R-1. LPA reviewed R-1’s file and did not observe any eviction letter. LPA interviewed 4 other residents and only one stated an eviction letter was given about 2 ½ years ago. There is no supportive evidence to concur with this allegation.

Allegation – Facility did not ensure that resident was receiving their medication while in care.
Administrator and Staff interviewed stated that the residents are all medication compliant. They take their medications daily and at the prescribed time. The Med Tech stated the medications are distributed in the medication room. The residents come down during their medication times and if a resident does not go during the medication period which rarely happens, the Med Tech will take it to them. LPA interviewed 5 residents and all 5 stated they take their medications daily. LPA reviewed the medication for 5 residents and it appears that the medications are administered in accordance with the physician’s orders.

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

An exit interview was conducted with the Administrator. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

LIC9099 (FAS) - (06/04)

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