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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 08/09/2022
Date Signed: 08/09/2022 06:06:53 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
08/01/2022 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20220801085432
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:
08/09/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Ruby Garcia TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff do not following COVID-19 protocols
Staff retaliate against resident
Staff make resident work
Staff do not treat residents with dignity in their relationship by speak harshly to residents
Staff call residents inappropriate names
Staff yell at residents
Facility does not supply napkins or paper towels for residents
Facility is in disrepair
Facility has insects
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 the staff #1 (S1) . Shortly after Administrator arrived. LPA explained the purpose of the visit.

The investigation consisted of the following: LPA conducted a tour of randomly selected client rooms, kitchen, dining room, common areas and outside patio area. Obtained copies of Staff & Resident Rosters and Maintainance log. LPA interviewed Client#1 to Client #10 (C1 to R10), Administrator and Staff #1 to Staff #5 (S1 to S5 ).

Continue 9099C
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: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
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 5
Control Number 28-AS-20220801085432
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: 08/09/2022
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Allegation 1: Staff do not following COVID-19 protocols. It was alleged that administrator gives clients unfiltered water from the water hose. Facility corridors is used to house clients that test positive for COVID.
Staff do not give clients mask unless they ask.
A tour of the outside patio area LPA observed two large sealed plastic containers approximately 5 gallons each filled with ice water. Per the Administrator, the staff check the containers every two hours. The staff will re-fill the containers at 6pm -7pm for the night. Staff will also re-fill the containers if the clients notify them that they are empty. Third big water container were observed in the dining room. All interviewed staff denied that administrator gives unfiltered water to clients from the water hose. Water containers re-filed with filtered water from the kitchen. Per interviews conducted with clients, some stated that they have not observed the drinking water running out and administrator or other staff give unfiltered water from the water hose to clients. Some state that they only drink bottled water. Interviewed clients also denied that staff not providing mask to them. LPA observed that all clients wearing mask at the time of visit. Interviewed Administrator and staff stated there are enough mask and other PPE supplies at the facility and they provide mask to all clients at all the time. At the time of visit LPA observed that the Covid test being conducted in the doctors office. There were no clients in the hallway being tested.


Allegation 2: Staff retaliate against resident. It was alleged that Administrator retaliates against C1 for complaining about the facility. Interviewed administrator and staff deny retaliating against any client who makes a complaint about the facility. Interviewed staff indicated Administrator do not retaliate against any clients nor have they observed other staff retaliate against clients.
Residents interviewed were unable to corroborate the allegation. Clients interviewed also deny feeling any retaliation or that they would from staff if they file a complaint. Clients stated that they were not aware that Administrator is retaliating against any client(s) at the facility.

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

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220801085432
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: 08/09/2022
NARRATIVE
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Allegation 3 : Staff make client to work. It was alleged that some clients clean the patio. The staff tell C2 to clean tables or this or do that, and C2 is not well.
Interviewed administrator and staff indicated that staff are not making clients work. They stated that there are clients that like to help out around the facility during their free time. Administrator stated that C2 times to times cleans the patio. Administrator indicated that C2 is doing that voluntarily. Interviews conducted with staff revealed that facility staff do not make any clients do work at the facility, clean the patio or clean the tables. Some clients likes to help and keep themselves busy. Interviewed C2 stated that staff not making them to work. C2 stated that he clean the patio voluntarily. 9 out of 10 interviewed clients stated that staff do not make them to work. they stated that the facility staff treat them with dignity and respect and they do not have any issues or concerns regarding staff or the facility.

Allegation 4 and 6 :Staff do not treat residents with dignity in their relationship by speak harshly to clients.


Administrator yell at the client. it was alleged that when Administrator doing Covid test, yells at client and rude. Staff harshly told C4 ( C1's roommate) to remove clothing and change the linen during their Covid quarantine.
9 out of 10 clients stated the staff and administrator are nice and denied that they speak harshly to them, yell at them or rude. Interviewed C4 ( C1's Roommate) stated that staff didn’t make C4 to change their linen during Covid quarantine time. 9 out of 10 clients stated that administrator not rude and didn’t yell at them during Covid testing process. The administrator and all staff stated that they do not violate the personal rights of the residents by speaking harshly to them or yelling at them. Each client is accorded dignity and respect. All interviewed staff denied the allegations. They stated staff didn’t make clients change their linen during quarantine and didn’t heard that administrator yelled at the clients or rude during Covid testing process.

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

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220801085432
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: 08/09/2022
NARRATIVE
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Allegation 5: Staff call residents inappropriate names. It was alleged that Administrator has called C1 "big booty" and "monster".

All interviewed staff denied making inappropriate comments or calling names C1 or any other clients and not heard Administrator or any other staff doing so. They stated they treat clients respectfully. 9 out of 10 interviewed clients denied that administrator or staff are calling C1 or other clients names. There are no witnesses to corroborate that facility Administrator or staff making inappropriate comments or calling clients names. LPA did not observe or hear that administrator or staff call clients with inappropriate name during the visit.


Allegation 7: Facility does not supply napkins or paper towels for residents. It was alleged that facility does not provide napkins or paper towels for client's meals.
During the tour LPA observed 2 storage rooms in the hallway and they were stocked with plastic disposable plates, cups, utensils, napkins and paper towels. Box of "Dinner napkins" were observed in the kitchen storage area. Administrator stated that kitchen staff always provide napkins for client's meal. Kitchen staff stated that they always put napkins in the serving trays and clients can ask for extra napkins if needed.
Interviewed clients stated that kitchen staff provide napkins for client's meal.



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

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220801085432
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: 08/09/2022
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Allegation 8: Facility is in disrepair. It was alleged that many of client rooms do not have a fan, windows not open and there is no air conditioning for clients. Often without warning, the electricity is off. At 10AM when the manager arrives, she turns the power breaker back on. The big patio is very dirty, and staff do not clean.

Administrator stated that facility doesn't have a central AC, but all client rooms have ceiling fans / portable fans / portable air conditioning units. During the facility tour LPA observed commercial fans in hallways and randomly chosen rooms were equipped with ceiling fans / portable fans / portable air conditioning units. All inspected rooms were clean and windows were functioning properly, there was no issues with opening or closing. Per administrator facility has extra portable fans in case if clients needed. LPA observed boxes of purchased fans in the hallway. Interviewed staff and clients stated if any thing is broken in client rooms they will report to maintenance and it will be fix as soon as possible. Administrator and staff denied that without warning, the electricity is off. They indicated one time power breaker turned off because there were to many electrical items plugged in. Staff backed on the power breaker immediately. During the tour LPA observed that outside patio is clean. Interviewed staff stated that staff cleaning facility every day including patio area.
Clients stated that facility staff clean the facility and their rooms every day. Clients indicated that they are comfortable in the facility.

Allegation 9: Facility has insects. It was alleged that there are flies in the dining room throughout the year.
During today's visit LPA did not observe any flies or any other insects in side of facility or in dining room. interviewed staff denied that there are flies in the dining room. Administrator reported that they keep the front and back doors closed. Interviewed clients stated there are flies outside but not in side of facility.

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 held with Administrator and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5