198602244-1-27-2022-28-AS-LHIS-CDDTPC-20220411145409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 01/27/2022
Date Signed: 01/27/2022 02:31:21 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
01/21/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220121163259

FACILITY NAME:	PASADENA ADULT LIVING CENTER		FACILITY NUMBER:	198602244
ADMINISTRATOR:	GARCIA, RUBY		FACILITY TYPE:	735
ADDRESS:	1415 N GARFIELD AVE		TELEPHONE:	(626) 398-9647
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	136	CENSUS: 97	DATE:	01/27/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Ruby Garcia, Administrator		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.
Staff speak inappropriately to resident.
Staff does not keep the facility clean and sanitary.
Staff are inspecting resident's personal items without cause.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegations. The purpose of the visit was discussed with Administrator Ruby Garcia.

The investigation consisted of the following: A tour of the interior and exterior physical plant was conducted. LPA observed and inspected all hallway floors, common areas, and outdoor courtyard area for cleanliness. No health and safety issues were observed. COVID-19 infection control/sanitiation was observed to be in place. Facility has active COVID-19 cases with red & yellow quarantine zones in place. Residents (R2 - R10) and staft (S1- S5) were interviewed. Copies of resident (R1's) file documents [Face Sheet, Admission Agreement, House Rules, Appraisal Needs and Services Plan, Physician Report, Eviction Notice], staff and resident rosters were obtained.

See LIC 9099C for continutation of report.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220121163259

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: 01/27/2022

NARRATIVE

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Allegation: "Staff handled resident in a rough manner." Based on interviews conducted and record review the findings indicate that the incident referred regarding this allegation did not occur on January 18, 2022. A previous complaint control : 28-AS-20210811134815 investigated in August 2021 regarding the alleged incident, which occurred on January 20, 2021 was completed and found to be Unsubstantiated. All staff interviewed denied any recent incidents involving resident (R1) and staff (S2). Staff confirmed there was incident between R1 and S2 last year in January 2021. A total of nine (9) residents were interviewed none have witnessed R1 being handled in a rough manner by S2. Staff (S2) denied handling R1 in a rough manner, and stated it does not speak to R1 at all in order to avoid incidents.

Allegation: "Staff speak inappropriately to resident." It is alleged that facility staff (S2) and staff (S3) harass resident (R1) with intimidation and call R1 names. Both staff (S2 & S3) denied this allegation, and stated resident (R1's) mental disability causes delusional paranoia. Resident (R1) frequently calls the Pasadena Police Department to report staff when the resident gets angry.There have been no recent incident reports involving S2, S3, and R1. Three (3) other staff were interviewed and none have witnessed S2 & S3 speak to R1 inappropriately. A total of nine (9) residents were interviewed all stated that staff (S2 & S3) do not harass or call R1 names. Per, file review R1 has behavioral and mental issues that cause delusions.

Allegation: "Staff does not keep the facility clean and sanitary." It is alleged that the facility hallway floors are dirty with urine, feces, and blood. Residents have been receiving meal tray service in their rooms since January 4, 2022 due to active COVID-19 cases, which caused the dining room to be closed to residents. There is concern that food/meals are transported through unsanitary hallway floor conditions. According to staff interviews, the facility hallway floors are cleaned and mopped at a minimum once per shift, but most of the time the floors are mopped several times during each shift because residents spill food as they carry their food through the hallways. LPA observed all hallways floor to be clean during today's visit. All residents interviewed stated the floors are cleaned everyday, and spills or accidents are immediately cleaned by staff.

See LIC 9099C for report continuation.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220121163259

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: 01/27/2022

NARRATIVE

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Allegation:" Staff are inspecting resident's personal items without cause." Based on interviews conducted resident (R1) refuses to allow housekeeping and Administration staff into the room to conduct housekeeping duties. The resident cleans its own room and gets aggressive when staff attempt to perform room checks as stated per House Rules. On December 1, 2021, Administrator went into R1's room and placed an Eviction Notice on the resident's bed. However, dresser drawers were no inspected. All housekeepers interviewed stated they do not check R1s drawer, and have not checked it in a long time because R1 becomes aggressively violent. All of the residents interviewed reported no issues with this allegation.

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 allegations are UNSUBSTANTIATED.

An exit interview was held with Administrator Ruby Garcia. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC9099 (FAS) - (06/04)

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