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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 10/13/2021
Date Signed: 10/13/2021 04:07:28 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
10/04/2021 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211004090522
FACILITY NAME:PASADENA ADULT LIVING CENTERFACILITY NUMBER:
198602244
ADMINISTRATOR:GARCIA, RUBYFACILITY TYPE:
735
ADDRESS:1415 N GARFIELD AVETELEPHONE:
(626) 398-9647
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:136CENSUS: 97DATE:
10/13/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator Ruby Garica TIME COMPLETED:
04:05 PM
ALLEGATION(S):
1
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9
Facility is not meeting the needs and providing adequate care to a resident.
INVESTIGATION FINDINGS:
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3
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5
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9
10
11
12
13
Licensed Program Analyst (LPA) Alberto Lopez met with Clarrisa Basto Medication Manager/Direct care and Administrator Ruby Garcia a few minutes later. LPA Lopez explained the purpose of the visit.

The investigation consisted of interviews with 11 clients (C1-C11) and four staff (S1-S4) and Administrator Ruby Garcia.
During this visit LPA obtained staff roster, client roster (LIC 500). For C1, LPA obtained Preplacement Appraisal, Face sheet, Physicians Report, Functional Capability Assessment, Appraisal Needs and services plan, Admission Agreement. Doctor Complaint Log (Psychiatrist)
Based on observations made and interviews conducted, the findings indicate that facility is meeting the needs and providding adequate care for the client.
Eleven (11) out of 11 clients stated they receive proper care and needs are being met by the facility.

conttinue on 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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 2
Control Number 28-AS-20211004090522
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 ADULT LIVING CENTER
FACILITY NUMBER: 198602244
VISIT DATE: 10/13/2021
NARRATIVE
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11/11 clients also reported their medications are dispensed on time. All clients stated that they know how to get help if needed and receive assistance in a timely matter.

Staff interviewed (S1-S4) all stated they meet client's needs and are accommodating to clients. Staff stated that they provide care and services for all clients.

Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) occurred, therefore the allegation is UNSUBSTANTIATED.

An exit interview was held with Administrator Ruby Garcia. A copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2