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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 12/10/2021
Date Signed: 12/10/2021 02:20:40 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
12/06/2021 and conducted by Evaluator Nune Margaryan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211206143301
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: 101DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Direct Care Staff Jennifer Tapia
and Administrator Ruby Garcia 		TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Client is being called names
Staff are not intervening when clients walk around with their pants down
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to investigate the allegations listed above. LPA met with Jennifer Tapia - Staff. Ruby Garcia - Administrator arrived shortly at 9:30 am. LPA explained the purpose of the visit.

The investigation consisted of the following: LPA Margaryan obtained a copies of the staff roster, clients roster, other relevant documents and interviewed Administrator at 9:33am, 4(four) staff at 11:30am to
12:30pm and 12 (twelve) clients at 9:15am to 11:30am.

The investigation revealed the following: Regarding allegation – Client is being called names. It is alleged that everyone is calling Client #1 (C1) vulgar/ inappropriate names. Administrator was made aware of by C1 that others called C1 inappropriate names. The Administrator did not hear it herself nor anyone else such as other staff or clients. She stated that C1 makes accusations often.
Continue to LIC9099C

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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-20211206143301
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: 12/10/2021
NARRATIVE
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All interviewed staff denied making inappropriate comments or calling names C1 or any other clients and not heard any other staff doing so. They stated they treat clients respectfully. All interviewed clients denied that staff or clients are calling C1 or other clients names. There are no witnesses to corroborate that facility staff or clients making inappropriate comments or calling clients names.

Based on interviews and observations there is no sufficient information to verify the allegation. Therefore, this allegation is Unsubstantiated.

Regarding Allegation - Staff are not intervening when clients walk around with their pants down. Administrator indicated that she was aware that C1 makes false accusations towards other clients and staff. However, no male clients ever observed walking their pants down in the facility. Administrator stated when staff see any clients wear inappropriately, they immediately address it and redirect clients. All interviewed staff and residents denied that male clients are walking around with their pants down or wearing inappropriate clothing.

Based on the interviews and observation there is no corroborating information to support the allegation.

Therefore, this allegation is Unsubstantiated.

Exit interview were contacted with the Administrator and copy of this report along with the appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2