197602925-12-14-2023-28-AS-LHIS-CYMRA6-20231218115038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602925
Report Date: 12/14/2023
Date Signed: 12/14/2023 03:18:45 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
12/12/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231212110800

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:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Kim Commodore, Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff made derogatory/racial statements towards resident.
Staff yells at residents.
Staff does not treat residents with dignity and respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit regarding the above allegations. The purpose of the visit was explained to Administrator Kim Commodore.

The investigation consisted of: A physical plant inspection of the facility, record review, and interviews with staff (S1- S6) and residents (R2- R10). Resident (R1) was not interviewed because they are hospitalized as a result of behavior incident dated 12/11/2023. The following documents were obtained:R1's Face Sheet, Admission Agreement/packet, Physician Report, medication list, Welbe Health Pacific Pace provider agreement, three (3) incident reports, Client Notes, LIC, LIC 500 Personnel Report, and resident roster.

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: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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-20231212110800

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: 12/14/2023

NARRATIVE

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Allegation: Staff made derogatory/racial statements towards resident. It is alleged a day shift staff (S2) has called resident (R1) a racial slur using the "N" word and also called them a "bald headed B word." A total of nine (9) residents were interviewed, of which two (2) residents stated that they have heard staff say derogatory words to residents. The residents did not want to disclose what was said, or the name(s) of staff. One (1) resident reported that R1 has cussed and threatened them. A total of six (6) staff were interviewed. All staff denied the allegation. They stated that resident (R1) is uncooperative and verbally, as well as physically aggressive towards staff. Staff reported that R1 says derogatory words/names to staff. It was also reported that R1 hit med-tech staff (S4's) forearm with the housekeeper's broom. None of the staff have heard other staff say derogatory words towards R1 or other residents. Per Client Notes, R1 has history of using derogatory words towards staff and residents, and not vice versa. There is insufficient evidence to corroborate the allegation.

Allegation: Staff yells at residents. It is alleged that Administrator (S1) has been overheard yelling/screaming at residents and stating "If you don't like how I do things there's the door." The date(s) of the alleged yelling is unknown. A total of nine (9) residents were interviewed of which three (3) stated that they have heard Administrator yell down the hallway at residents in general, because they refused to stay in their rooms during a recent COVID virus outbreak isolation period. All staff denied the allegation, and acknowledged that Administrator has a loud voice tone that could be misconstrued as yelling, but when residents are addressed in a loud voice it is never in a disrespectful manner. Staff (S1) stated that they talk loud to both residents and staff, but never in a shouting or screaming manner. LPA confirmed that S1's natural voice tone is loud and residents are addressed in a respectful manner. Based on interviews conducted, the findings indicate that S1/Administrator's voice is boisterous but professional.

Allegation: Staff does not treat residents with dignity and respect. According to information obtained it is alleged that facility staff speak to residents "like babies" and residents do not like it. Based on interviews conducted the allegation could not be supported because only one (1) resident out of nine (9) residents interviewed stated that S1 and S5 address residents in a babyish way because they try too hard to treat residents well. In addition, the resident stated that staff (S4) has been overheard getting impatient with residents and whining about residents. All staff interviewed stated they treat all residents with dignity and respect, and some residents are addressed in a more sweet and parental manner because they respond better to that approach, and it uplifts their mood and self esteem. LPA observed satisfactory staff treatment towards residents, as well as good rapport.

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 and a copy of the report was issued to Administrator Kim Commodore.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

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