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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:48:10 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
10/27/2021 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211027130723
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:
11/04/2021
UNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Ruby GarciaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident being harassed at the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley initiated a 10 day complaint investigation for the allegation listed above. LPA met with Administrator Ruby Garcia and discussed the purpose for todays visit.

The investigation consisted of the following: LPA Wesley interviewed Administrator Ruby Garcia, interviewed residents, interviewed staff, and requested the following documents: staff roster, resident roster, staff training, and specific documents.

Regarding allegation: Resident being harassed at the facility. LPA Wesley interviewed a random selection of residents and they stated they were not being harassed by staff or residents in the facility and has never witnessed any residents get harassed by any staff. Staff were interviewed and indicated they have not harassed any of the residents or have witnessed any other staff harass the residents. During the interview with Staff #2, they advised that they were actually harassed by another resident and the police had to be called. Administrator
Continued on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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-20211027130723
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: 11/04/2021
NARRATIVE
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advised that some of the residents have disagreements, but she has never witnessed any of the residents harassing each other. Administrator Ruby Garcia said she has never harassed any residents, and has not witnessed any staff harassing the residents. LPA Wesley made repeated attempts to interview resident #1(R1) to gather specific information, but was not successful. The investigation revealed the following: There is insufficient evidence to support the allegation Resident being harassed at the facility.

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


There are no deficiencies cited. A copy of this report was given to the Administrator during the exit interview.
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2