198602244-4-10-2023-28-AS-FFIS-CQUT33-20230413142141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 04/10/2023
Date Signed: 04/10/2023 05:08:36 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
02/06/2020 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20200206154936

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: 91	DATE:	04/10/2023
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Jay Viado, Supervisor		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff does not provide resident adequate care and supervision.

INVESTIGATION FINDINGS:

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***This report serves as an amendment and supersedes the original complaint investigation report created on 03/24/23. The findings remain as Unsubstantiated. ***

Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent complaint visit to the facility regarding the above-mentioned allegation. Upon arrival at the facility, LPA met Jay Viado, Supervisor, and the purpose of today’s visit is to re-deliver finding.

On 02/13/20, LPA Tao conducted the initial investigation visit at the facility. LPA obtained client roster, staff roster, Client #1’s (C1) files including Identification and Emergency Information, Preplacement Appraisal Information, Physician's Report, Appraisal/Needs and Services Plan and Unusual Incident/Injury Report. A physical plant was conducted. Interviews were conducted including staff from staff #1 (S1) through staff#3 (S3) and clients from client#2 (C2) to client#13 (C13). LPA attempted to interview client#1 (C1) but all attempts failed. (- continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

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-20200206154936

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: 04/10/2023

NARRATIVE

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***This report serves as an amendment and supersedes the original complaint investigation report created on 03/24/23. The findings remain as Unsubstantiated. ***

On 04/20/22, LPA Gail Johnson and Licensing Program Manager (LPM) Ulysses Coronel conducted a subsequent visit at the facility, interviewed administrator, Staff#1 (S1), reviewed client#1’s files, toured the facility, and delivered finding.

On 03/24/23, LPA Tao conducted another subsequent visit. During the visit, LPA obtained copies of staff and client rosters, interviewed administrator, reviewed clients’ files, conducted a facility tour, and delivered findings.

On 04/10/23, LPA Tao conducted another subsequent visit to re-deliver finding.

The investigation consisted of resident interviews, staff interviews, residents’ files review, and facility tour.

The investigation revealed the following. Regarding the allegation “staff does not provide resident adequate care and supervision,” it is alleged that the facility is not preventing C1 from absent without leave (AWOL). On 02/13/2020, LPA Tao interviewed thirteen (13) clients and three (3) staff. LPA Tao attempted to interview Client #1 (C1) for multiple times at different time and on different days. All attempts failed. Eight (8) out of thirteen (13) clients interviewed could not corroborate the allegation. Four (4) out of thirteen (13) clients denied to be interviewed.

All three (3) staff interviewed denied the allegation. On 4/20/2022, LPA Gail Johnson conducted record reviews indicated that the facility’s in-house psychiatrist was in contact with C1 from 12/03/2014 to 02/26/2020 and needs and services plan were conducted on an annual basis. The most recent needs and services plan was conducted on 05/02/2019. On 04/20/2022, Administrator Garcia stated the facility is not a locked facility, clients had right to come and go as they please. During clients’ admission, facility had advised clients to use the sign out sheet to notify staff on when clients planned to come back and where they were going. Administrator would file a missing person police report within 24 hours if clients are AWOL. C1 went AWOL on 06/01/2020 and never returned.

(- continued in LIC 9099 C-)

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200206154936

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: 04/10/2023

NARRATIVE

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***This report serves as an amendment and supersedes the original complaint investigation report created on 03/24/23. The findings remain as Unsubstantiated. ***

On 3/24/23, LPA Tao interviewed administrator, Ruby Garcia, and said C1 was able to go out in the community on his/her own per C1's physician report. Per file review, administrator had filed a missing person’s report with law enforcement and incident report to Licensing on 02/14/20.

Therefore, per file reviews and client/staff interviews, staff provided clients with adequate care and supervision.

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

An exit interview was conducted. A copy of this report was provided to Jay Viado, Supervisor.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC9099 (FAS) - (06/04)

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