198602244-5-12-2022-28-AS-MVAO-CF8SED-20220609134834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 05/12/2022
Date Signed: 05/12/2022 02:04:31 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
07/28/2021 and conducted by Evaluator Elizabeth Irra

COMPLAINT CONTROL NUMBER: 28-AS-20210728162010

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: 98	DATE:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Ruby Garcia		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Client is being harassed by other client while in care.
Client was physically abused while in care.

INVESTIGATION FINDINGS:

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On 08/05/2021, Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with the Facility Administrator and discussed the purpose of today's visit. During this visit, LPA obtained a Staff Roster and Client Roster. LPA obtained relevant documentation for Client #1 (C-1) and Client #4 (C-4). LPA interviewed Facility Administrator and Client #3 (C-3). Client #2 (C-2) refused to be interviewed. C-1, C-4, C-5, C-6, C-7 and C-8 were not present during this visit.

During today's visit, LPAs Elizabeth Irra and Bennette Pena interviewed C-4,C-5, C-6, C-7, C-8, S-1, S-2 and S-3. C-1 refused to be interviewed.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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-20210728162010

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: 05/12/2022

NARRATIVE

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Allegation: Client is being harassed by other client while in care. During this investigation, LPA obtained relevant documentation for Client #1 (C-1) and Client #4 (C-4). LPA interviewed Facility Administrator, Client #3 (C-3), Client #4 (C-4), Client #5 (C-5), Client #6 (C-6), Client #7 (C-7) and Client #8 (C-8). Client #1 (C-1) and Client #2 (C-2) refused to be interviewed. LPA also interviewed Staff #1 (S-1), Staff #2 (S-2) and Staff #3 (S-3). Client interviews revealed that they have not been harassed and/or stalked (sexually, physically nor verbally) nor have they witnessed anyone being harassed and/or stalked by others. Client interviews revealed that they (including staff) do not curse nor yell nor have they witnessed anyone yelling or cursing at others. Staff interviews revealed that they have not witnessed nor have they harassed and/or stalked anyone (sexually, physically nor verbally). Staff interviews revealed that they do not yell nor curse at others. Staff interviews also revealed they are trained in Mandated Reporting and Client Rights. Client and Staff interviews do not corroborate this allegation.

Allegation: Client was physically abused while in care. During this investigation, LPA obtained relevant documentation for Client #1 (C-1) and Client #4 (C-4). LPA interviewed Facility Administrator, Client #3 (C-3), Client #4 (C-4), Client #5 (C-5), Client #6 (C-6), Client #7 (C-7) and Client #8 (C-8). Client #1 (C-1) and Client #2 (C-2) refused to be interviewed. LPA also interviewed Staff #1 (S-1), Staff #2 (S-2) and Staff #3 (S-3). Client interviews revealed that they have not been physically abused nor have they witnessed anyone being physically abused by others. Staff interviews revealed that they have not witnessed nor have they have physically abused anyone. Staff interviews also revealed they are trained in Mandated Reporting and Client Rights. Client and Staff interviews do not corroborate this allegation.

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

Exit interview was conducted, appeal rights provided and a copy of this report was provided to Facility Administrator

Note: LPA experience technical difficulties during this visit.

NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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