197602925-12-9-2022-28-AS-MVAO-CMHUG6-20221227143350

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602925
Report Date: 12/09/2022
Date Signed: 12/09/2022 03:27:36 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
10/25/2021 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211025135008

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: 54	DATE:	12/09/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Kim Commodore		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff provide care and supervision while under the influence of drugs
Staff do not properly assist residents with their medications
Staff speak inappropriately to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Kim Commodore and explained the reason for the visit.
The purpose of the visit is to deliver the findings for the above allegations from original complaint dated 10/25/2021.
Initial visit was conducted 1/02/2021 which included interviews with Administrator, Staff #1- Staff # 3 and a subsequent visit was conducted on 12/01/2021 which included Resident's 1-8 who were interviewed.
In regards to the allegation Staff provide care and supervision while under the influence of drugs, based on interviews conducted and information gathered it was revealed by interviews with residents that Staff S1 is a good worker and is nice to them. Stated they have never seen him drinking or doing drugs. Said he is very good and helpful and professional. Stated that the Administrator would never put up with that.
Staff interviewed stated that S1 does a professional job and is good to the resident and will work all day alongside him and never seen him under the influence of drugs.
Staff also stated that the Administrator would never put up with that.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022

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 4

Control Number 28-AS-20211025135008

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: 12/09/2022

NARRATIVE

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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
In regards to the allegation Staff do not properly assist residents with their medications, based on interviews conducted and information gathered it was revealed in interviews with residents that Staff are good with meds.
They have never received anyone elses meds and never gotten wrong meds. Two residents here 4 and 12 years stated they had never missed a medication.
Staff interviewed stated that all medications are administered properly and no one at any time will get someone elses medication.
Stated that there are occasions where residents have forgotten they were already given medication and say they didn't get it.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
In regards to the allegation Staff speak inappropriately to residents in care, based on interviews conducted and information gathered residents interviewed stated that S1 is not inappropriate and has not used bad language. Said they have not heard staff talk negatively to residents. Stated that staff may have to be stern with certain residents, but never are inappropriate using bad language and Administrator would never put up with that.
Staff interviewed stated that they have never seen or observed anything inappropriate. Said there is an In service and they first thing they say is if you see something you say something. There is a hotline with the company to report anything. Also stated Administrator would not put up with it and there is zero tolerance and any negative concerns are addressed immediately with the Administrator.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
10/25/2021 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211025135008

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: 54	DATE:	12/09/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Kim Commodore		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff does not have proper training

INVESTIGATION FINDINGS:

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In regards to the allegation Staff does not have proper training, based on interviews conducted and information gathered it was revealed in interviews with residents that Staff S2 performs janitorial duties and is also administering meds all the time and does not have training.
Stated that S2 has been administering medication to residents for many months.
Interview with S2 who confirmed he has administered medications to help assist on all shifts and does not have medication certificate training.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is cited. See LIC 9099D.

Exit interview was conducted with Administrator Kim Commodore. A copy of the report and appeal rights were provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20211025135008

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/09/2022 Section Cited CCR 87411(c)(D)	1 2 3 4 5 6 7	Personnel Requirements - General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility Administrator submitted medication certificate for Staff S2. Deficiency cleared.
	8 9 10 11 12 13 14	Based on interviews conducted facility failed to have Staff S2 receive medication training which caused an Immediate Health and Safety Risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4