198602244-4-4-2022-28-AS-SCOL-CD8VQZ-20220406163911

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 04/03/2022
Date Signed: 04/04/2022 03:55:06 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
11/16/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20211116150849

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: 99	DATE:	04/03/2022
		UNANNOUNCED	TIME BEGAN:	03:17 PM
MET WITH:	Ruby Garcia - Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Client room door is in disrepair

INVESTIGATION FINDINGS:

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*This report supersedes report created on 11/19/21 to correct finding substantiated and provide corrected finding for the above allegation.*
On 4/3/22 LPA Flores contacted administrator over the phone and explained the reason for the corrected report. On 11/19/21 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)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2022

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-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: 04/03/2022

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 circle hole of about an inch/quarter size, in the outside surface of the room's door without visibility to the inside of 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.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Ruby Garcia administrator and a copy of this report was email for signature and a hard copy will be place in the file.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2022

LIC9099 (FAS) - (06/04)

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