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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 09/06/2022
Date Signed: 09/06/2022 02:05:29 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
10/23/2020 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201023155454
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: 95DATE:
09/06/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Ruby GarciaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident is being sexually harassed by another resident in care.

Resident is being threatened by a former resident while in care.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #3 (S3: Jennifer Tapia, Direct Care Staff) and later met with Administrator (A1: Ruby Garcia). LPA/RA spoke to S1 prior to entering the facility to conduct a risk assessment. Staff #3 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of this visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day virtual visit was conducted by LPA Joe Katrdzhyan on 10/29/20 (via telephone) with Administrator Garcia due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed (between 10:00 a.m. - 11:30 a.m.) four (4) staff members and five (5) clients in care. LPA/RA reviewed (between 8:45 a.m. - 9:30 a.m.) pertinent documents: Admission Agreement, Emergency I.D. & Information, Physician’s Report, Appraisal/Needs and Services Plan, Personal Rights, and Unusual Incident/Injury Report re: Client #1 and (former) Client #2; and staff Mandated Reporter Training.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 09/06/2022
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-20201023155454
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: 09/06/2022
NARRATIVE
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Regarding Allegation #1: this investigation revealed that (former) Client #2 would wear saggy pants and while standing in line for their medications on 10/29/20, Client #1 observed Client #2's pants to be sagging too much. Client #1 felt sexually harassed by Client #2 because the client refused to adjust the saggy pants. A1 observed the incident and advised Client #1 that Client #2 has personal rights for dress attire and cannot be violated of those personal rights. Interviews conducted corroborated that they have not been sexually harassed by another client nor observed other clients being sexually harassed by another client in care. Majority staff interviewed corroborated that they have received the Mandated Reporter Training upon hire.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Resident is being sexually harassed by another resident in care is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that (former) Client #3 continues to return to the facility after moving five (5) years ago in 2017 to visit former acquaintances that reside at the facility. Client #1 will avoid (former) Client #3 whenever former Client #3 is at the facility visiting acquaintances. Interviews conducted corroborated that (former) Client #3 visits other acquaintances residing at the facility; but, they do not feel threatened by Client #3 nor do they wish to have their personal rights violated by whom can visit these clients at the facility. LPA/RA toured the facility grounds and observed the self-locking exit gates and the front main entrance self-locking door (with an adjacent intercom system) for after-hour visitation use.

Based on the evidence gathered and interviews conducted and observations, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Resident is being threatened by a former resident while in care is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Administrator (Ruby Garcia).

NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 09/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/23/2020 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201023155454

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: 95DATE:
09/06/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Ruby GarciaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not assuring a residents safety.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #3 (S3: Jennifer Tapia, Direct Care Staff) and later met with Administrator (A1: Ruby Garcia). LPA/RA spoke to S1 prior to entering the facility to conduct a risk assessment. Staff #3 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of this visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day virtual visit was conducted by LPA Joe Katrdzhyan on 10/29/20 (via telephone) with Administrator Garcia due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed (between 10:00 a.m. - 11:30 a.m.) four (4) staff members and five (5) clients in care. LPA/RA reviewed (between 8:45 a.m. - 9:30 a.m.) pertinent documents: Admission Agreement, Emergency I.D. & Information, Physician’s Report, Appraisal/Needs and Services Plan, and Personal Rights for Client #1. No records review for (former) Client #3; as the client moved on or about five (5) years in 2017.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 09/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20201023155454
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: 09/06/2022
NARRATIVE
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Regarding Allegation #3: this investigation revealed the facility has seven (7) self-locking exits; however, clients in care will leave the east side gate ajar (with a rock) to regain entrance; but, it also invites passer bys to gain entrance onto the facility grounds; and, passer bys have entered the main building of the facility to use the common bathrooms. The facility has a contracted security company that monitors the exits after hours; however, interviews conducted corroborated passer bys will enter (via the east side gate) after visiting hours instead of using the front main door (with intercom system) to gain entrance. During a physical tour of the facility grounds, LPA/RA Ceniceros' observed the east side gate ajar (photograph).

Based on the evidence gathered, interviews conducted, and observations, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE: Staff are not assuring a residents safety is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency was observed and citation issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to Administrator (Ruby Garcia)

NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

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

DATE: 09/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20201023155454
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: 09/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/20/2022
Section Cited
CCR
80072(a)(2)
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PERSONAL RIGHTS: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful, and comfortable accommoda- tions, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:
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Licensee to ensure that all self-latching gates remain closed at all times so passerbys do not gain entrance onto the facility grounds. Please submit a plan of correction documenting reviewing Section 85065.6 to ensure staff are assuring residents safety at the facility.
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(Cont) LPA/RA observed the east side gate ajar (photo) which allowed a passerby to gain entrance onto the facility grounds.
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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: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

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

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