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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:50:54 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
06/03/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220603151552
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: 97DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Ruby Garcia, AdministratorTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Staff did not prevent resident from engaging in physical altercation with another resident.
Resident sustained injury while in care.

INVESTIGATION FINDINGS:
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Licensing Program Analysta (LPAa) Galarza and Ya Ting Yang conducted an unannounced visit regarding the above allegations and delivered findings. The purpose of the visit was explained to Administrator Ruby Garcia

The investigation consisted of: A physical plant tour of the interior and exterior was conducted. Staff (S1- S4) and clients (C1-C12) were interviewed. Video surveillance of incident dated 5/31/2022 was reviewed. The incident occurred at 10:57 AM. The following documents were obtained pertaining to client (C1 & C2): Face Sheet, Physician Report, Appraisal Needs and Services Plan, incident report (5/31/22), Preplacement Appraisal Information, LIC 500 Personnel Report, resident roster, and C1's notes to Administrator.

See LIC 9099C for report continuation.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
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 3
Control Number 28-AS-20220603151552
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: 06/09/2022
NARRATIVE
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Allegation: "Staff did not prevent resident from engaging in physical altercation with another resident." On 5/31/2022, client (C1) was hit in the face by client (C2) while waiting in line to receive Personal & Incidental funds. Video surveillance was reviewed during today's visit. The alleged incident occurred at 10:57 AM outside the staff office where staff (S1 & S2) were at. It took staff (S2) 22 seconds to respond and address the verbal altercation that resulted in the physical incident between C1 & C2. Based on video staff should have attended to the verbal altercation between the clients, in order to prevent the physical incident. Based on interviews conducted and file review client (C2) has history of hitting clients and aggression. Client (C2) has hit a total of four (4) clients in the last several months. The most recent incident reported was yesterday. Client (C2) shoved client (C3) in the dining room. Client (C3) hit it's head on the wall. Therefore, staff shall provide care and supervision necessary if it is known that client(s) engage in verbal and/or physical altercations while they are in the same area. A total of 12 clients were interviewed, of which four (4) stated staff do not prevent physical altercations between residents. All staff denied this allegation. However, video surveillance confirmed the incident could have been prevented if staff had responded sooner.

Allegation: "Resident sustained injury while in care." Based on interviews conducted and review of video surveillance review the findings indicate that on 5/31/2022 client (C1 & C2) had a verbal altercation outside the staff office. Video surveillance showed client (C2) approached client (C1) threatened to punch the resident, and 2 seconds later punched client (C1) in the face. Client (C2) punched C1 with force, and continued to threaten C1 after staff responded to the incident. There were two other residents present during the incident. Staff checked C1 for injuries, and at the time no visible injuries were observed. However, C1 developed blue/black bruising on the left side of the cheek. During today's visit, LPAs observed the cheek had marks of a faded bruise. Five (5) out 12 clients interviewed confirmed C1 was hit by C2. Client (C2) acknowledged punching C1 in the face. Client (C2) stated "they get me mad they deserve to be hit." Staff interviews confirmed the incident resulted in injury.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. Deficiency is cited. See LIC 9099D.

Exit interview was conducted with Administrator Ruby Garcia. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220603151552
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: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/30/2022
Section Cited
CCR
80078(a)
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80078(a). Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met evidenced by:
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Administrator agrees to conduct staff training pertaining to allegation 80078 and all other staff responsibilities pertaining to safety and resident care.

Submit proof of POC by due date.
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Based on interviews conducted and surveillance video review the findings indicate that on 5/31/22, C1 was punched in the face by C2, which could have been prevented by staff since the incident began as a verbal altercation that escalated. Staff were in the same vicinity. This poses a potential health and safety risk to residents in care.
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Deficiency Dismissed
Type B
06/30/2022
Section Cited
CCR
80072(a)(1)
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Personal Rights. To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement was not met evidenced by:
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Administrator shall conduct staff training and agrees to submit a written plan stating how this deficiency was corrected.

Submit proof of staff training and written plan by POC due date.
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Based on interviews conducted and surveillance review on 5/31/22, C1 was physically attacked by C2.Client (C1) and C2 have history of verbal altercations that C1 has reported to staff. C1 expressed its personal rights are not being protected. This poses a potential health and safety risk to residents 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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3