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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 11/19/2021
Date Signed: 11/19/2021 03:14:24 PM

Substantiated


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
11/16/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20211116150849
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: 98DATE:
11/19/2021
UNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Ruby Garcia Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Client room door is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Ruby Garcia administrator and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested a copy of the facility's client and staff roster, and conducted a tour with Ruby Garcia of the following randomly chosen rooms:#105,110,119,128,202,218, 226,228, and attempted to look room #128. Doors in room's #128 and #130 have one circular hole of about an inch each. LPA Flores interviewed client #1(C1),#2(C2),#3(C3),#4(C4),#5(C5),#6(C6),#7(C7),#8(C8) and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5), administrator, and client #9(C9) over the phone.

(CONTINUED ON LIC 9099)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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 5
Control Number 28-AS-20211116150849
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: 11/19/2021
NARRATIVE
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Regarding allegation: Client room door is in disrepair. It is alleged client has two holes in her door and has not been repair. During facility's tour LPA observed room #128 and #130 each had one hole of about an inch, in the outside surface of the room's door without visibility to the room. Administrator stated room #128 had the hole for about a week and room #130 did not had a hole until today. Administrator provided LPA with a maintenance log which has a request for repairs needed for those two rooms. Request for room #128 on 11/17/21 and request for room #130 on 11/19/21. Interviews with 8 out 9 clients revealed doors are in good repair, and have not observed holes in the doors. Interview with 1 out of 9 clients revealed door has had holes done by previous client residing in room and has not been repair. Interviews with 5 out 5 staff revealed door are in good condition able to lock, open and closed, and if there is need for repair for holes a request is place to maintenance and handle right away.

Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found Substantiated. California Code of Regulations Title 22,
Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview conducted with Ruby Garcia administrator and a copy of this report, LIC 9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
11/16/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20211116150849

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: 98DATE:
11/19/2021
UNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Ruby Garcia Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not providing a comfortable environment for client
Staff are not preventing inappropriate interactions between clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Ruby Garcia administrator and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested a copy of the facility's client and staff roster, and conducted a tour with Ruby Garcia of the following randomly chosen rooms:#105,110,119,128,202,218, 226,228, and attempted to look at room #128. Doors in room's #128 and #130 have a circular hole of about an inch each. LPA Flores interviewed client #1(C1),#2(C2),#3(C3),#4(C4),#5(C5),#6(C6),#7(C7),#8(C8) and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5), administrator, and client #9(C9) over the phone.

The investigation revealed the following: Regarding allegation: Staff are not providing a comfortable environment for client: It is alleged client is tired of being harassed by another client who bangs on door all the time. (CONTINUED ON LIC 9099)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20211116150849
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: 11/19/2021
NARRATIVE
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Interviews with 7 out of 9 clients revealed clients feel comfortable at the facility do not feel others impose or disrespect them. Interviews with 2 out of 9 clients interviewed revealed clients have felt uncomfortable due to clients yelling or walking into the rooms without asking. Interviews with 5 out 5 staff revealed the facility environment is not uncomfortable for themselves or clients in care. 1 out of the 5 staff stated that residents do yell but not to harm others, and clients visit each other in their rooms.

Based on LPA's interviews, conducted the preponderance of evidence standard has been met, therefore the
above allegation(s) are found Unsubstantiated..

Regarding allegation: Staff are not preventing inappropriate interactions between clients. It is alleged client bangs on bathroom door on the wall and follows client around and is always screaming at the other clients. Interviews with 7 out of 9 clients stated to not observed inappropriate behaviors, such as yelling, arguing, banging on doors. 1 out 9 clients stated there is constant yelling at the facility from clients and 1 out of 9 clients stated client bangs at door and comes to room at all times. Interviews with 5 out 5 staff revealed clients do not behave inappropriate and have not observed inappropriate behaviors or heard of any client feeling mistreat. 1 out of the 5 stated inappropriate behaviors are not tolerate at the facility.

Based on LPA's interviews, conducted the preponderance of evidence standard has been met, therefore the
above allegation(s) are found Unsubstantiated.

Exit interview was conducted with Ruby Garcia Administrator and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20211116150849
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds: (a) (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.



This requirements is not met as evidence by:
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Licensee will ensure that facility is in good repair at all times, and will fix and submit pictures of doors in room #128, and #130 by 11/29/21.
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Based on LPAs observation licensee did not ensure that doors in room #128 and #130 are in good repair as each had a hole of about an inch which poses a potential health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5