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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 03:49:25 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
04/20/2021 and conducted by Evaluator Nicol Wesley
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210420143936
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:
01:00 PM
MET WITH:Ruby Garcia TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff threatened resident.
Staff makes inappropriate comments towards resident.
Staff did not prevent residents from making inappropriate comments towards resident.
Unlawful evictions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nicol Wesley initiated a complaint investigation for the allegations listed above. LPA Wesley met with Administrator Ruby Garcia to discuss the purpose for todays visit.

The investigation consisted of the following: On 04/26/21, LPA Wesley conducted a telephonic interview with Administrator Ruby Garcia, interviewed staff, resident #1(R1) and a random selection of residents. LPA Wesley requested the following documents: staff roster, resident roster, and any eviction notices(3 day/30 day) issued to residents in the 2021 year to be emailed/faxed to Nicol Wesley by 04/28/21.

Regarding allegation: Staff threatened resident and Staff makes inappropriate comments towards resident. LPA interviewed Administrator Ruby Garcia who said that she has never harassed, threatened, cursed out, or ran up and kicked and residents door. Administrator also said they have never made threats to attack or throw any of the residents belongings out of the house(facility).
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-20210420143936
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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LPA Wesley interviewed residents who said the Administrator has never made inappropriate comments, harassed, or threatened them in any way and they have never witnessed the Administrator harass, threaten or make in appropriate comments to R1. LPA Wesley interviewed R1 and who advised that Administrator Garcia threatened to throw their belongings away and during the interview, the allegation shifted and R1 stated they imagined the Administrator being harassing them and making inappropriate comments. There is in sufficient evidence to support the allegations.


Regarding allegation: Staff did not prevent residents from making inappropriate comments towards resident. Administrator Garcia advised that she has never witnessed any other residents call R1 racial names and curse at them, and has never witnessed this happen with any other residents. Administrator Garcia said that R1 doesn't communicate with any of the residents and is always alone. Administrator said the residents will argue and have disagreements, but she has never witnessed any of the residents making racial comments to each other. LPA interviewed staff who said they have never witnessed the Administrator or any other residents making racial comments to R1, and has never witnessed any other residents arguing and making racial comments with each other. The investigation revealed the following: There is insufficient evidence to support the allegation.

Regarding allegation: Unlawful evictions: The Administrator advised that a 30 notice had been issued to R1 in April 2021 for failure to pay rent, violating the facility house rules, failure to take prescribed medication, and failure to seek medical attention. The investigation also revealed that R1 has not paid rent to date. During the interview with R1 they advised that the Administrator told them they only had to pay $20, then switch it to $50 the next month and now changed it to $100 a month. R1 said they paid a total $2000, to live in the facility and is not going to pay anymore rent because the courts and their social worker placed them in the facility, so why should they have to pay. The Administrator said that the facility charges resident's the required board and care rate according to the Social Security Administration, and denied telling R1 they were only responsible to pay such small amount.

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)
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