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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 11/20/2023
Date Signed: 11/20/2023 02:57:05 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/21/2022 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220121155956
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: 86DATE:
11/20/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Clarissa Basto - Medication Supervisor TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff feeding residents on the floor
Staff not meeting residents nutritional needs
Staff does not distribute resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial complaint visit regarding the allegations listed above. LPA met with Clarissa Basto, Medication Supervisor for the facility, and explained the purpose for the visit. Administrator Ruby Garcia arrived shortly thereafter.

The investigation consisted of the following: LPA conducted a tour of the facility including the kitchen during lunch time, along with rooms #128 and #130 along with their jack-and-jill style bathroom, interviewed Clients #1 - 9 (C1 - C9), and Staff #1 - 6 (S1 - S6). LPA also obtained a copy of the client and staff rosters, along with meal menu for the facility as well.

The investigation revealed the following: in regards to the allegation "Staff feeding residents on the floor", it is alleged that the facility staff have served plates of food to the clients in their rooms and on the floor.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
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 6
Control Number 28-AS-20220121155956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA ADULT LIVING CENTER
FACILITY NUMBER: 198602244
VISIT DATE: 11/20/2023
NARRATIVE
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During interviews with the clients, nine (9) out of nine (9) did not corroborate the allegation that the staff serve food on the floor to clients. C1 indicated that sometimes clients place food on the floor in their rooms after they clean, but that the staff themselves do not serve clients food on the floor. All other clients indicated that they have never been served food on the floor by staff. During interviews with the staff, none of them corroborated the allegation that staff serve food on the floor to clients. LPA interviewed S4 and S5 who work as kitchen supervisor and servers respectively and stated that food has never been served to clients on the floor. Both S4 and S5 explained that all clients are served in the dining room, and that clients let them know what portions they want, it is then served on a plate, and then put on a line for the clients to pick up. LPA toured the kitchen during lunch time at 12:00 PM and observed kitchen staff preparing and serving food for all clients in the kitchen and dining hall of the facility.

Regarding the allegation "Staff not meeting the resident's nutritional needs", it is alleged that the facility staff have not been offering clients seconds during mealtime when they ask for seconds. During interviews with the clients, nine (9) out of nine (9) interviewed did not corroborate the allegation that their nutritional needs are not met, and that they are not provided seconds during meal time. C1 stated that this allegation is not true and that all the clients of the facility are offered seconds when they ask for it. All other clients agreed that they get seconds when they ask for it, and that they are satisfied with the quality of the food that is served. During interviews with the staff, all denied the allegation that clients are not offered seconds when they ask for it. S1 explained that clients are always provided seconds during mealtime if they ask for it, and that the facility always has plenty of food for the clients. S4 and S5 who work as kitchen staff also both stated that clients are always served seconds if they request it.

Regarding the allegation that "Staff does not distribute client's medications," it is alleged that the facility staff have not been distributing medications to clients. During interviews with the clients, nine (9) out of nine (9) did not corroborate that the facility staff do not assist in distributing their medications to them. All of the clients interviewed explained that they always get their medications every day, and that the facility staff do assist in distributing medications to them. During interviews with the staff, none of them corroborate the allegation that the facility does not distribute medications to residents. LPA interviewed S3 who is the medication supervisor for the facility, and they explained that the facility has a medication book that they mark when clients are provided their medications, and that they look for clients if they notice they have not been given their medication.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20220121155956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA ADULT LIVING CENTER
FACILITY NUMBER: 198602244
VISIT DATE: 11/20/2023
NARRATIVE
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S1 also explained that medications are medications are typically served during meal times in the morning, afternoon, and night, and that bedtime medications are provided to clients at the office and given with a snack.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/21/2022 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220121155956

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: 86DATE:
11/20/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Clarissa Basto - Medication Supervisor TIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Resident shower in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial complaint visit regarding the allegations listed above. LPA met with Clarissa Basto, Medication Supervisor for the facility, and explained the purpose for the visit. Administrator Ruby Garcia arrived shortly thereafter.

The investigation consisted of the following: LPA conducted a tour of the facility including the kitchen during lunch time, along with rooms #128 and #130 along with their jack-and-jill style bathroom, interviewed Clients #1 - 9 (C1 - C9), and Staff #1 - 6 (S1 - S6). LPA also obtained a copy of the client and staff rosters, along with meal menu for the facility as well.

The investigation revealed the following: in regards to the allegation "Resident shower is in disrepair", it is alleged that the jack-and-jill style shared restrom that is between rooms #128 and #130 have marble that is not clean to sit in, and that the bath tub water runs concurrently with the shower head when the water is turned on.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20220121155956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA ADULT LIVING CENTER
FACILITY NUMBER: 198602244
VISIT DATE: 11/20/2023
NARRATIVE
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During interviews with the clients, two (2) out of nine (9) clients corroborated the allegation that their shower is in disrepair. LPA interviewed C1 and C2 who shared the bathroom between rooms #128 and #130, and they both expressed that they feel the bathtub is rusty and dirty, and that one of the handle bars in the bathroom is broken. LPA toured the restroom in question and did observe that there was rust and apparent mold in the bathtub of the shower, and that the water from the bath tub faucet runs concurrently with the water from the shower head when the water is turned on. Pictures were taken of the state of the shower and bathtub as well. During interviews with the staff, none of them corroborated the allegation that any of the client showers are in a state of disrepair. S6 a maintenance staff stated that they check client restrooms every day to ensure that they are functioning properly, and that if any client informs S6 that their shower is not functioning, then S6 will immediately check them to ensure they are operational and clean as well. LPA toured the Jack-and-Jill style bathroom between rooms #128 and #130 with S1 and S6, and they explained that they will work on sanding the bathtub and repainting it.

Based on LPA's interviews conducted with the clients and staff, along with observation of the restroom between client bedrooms #128 and #130, the preponderance of evidence standard has been met for the above allegation, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC9099D.

Exit interview held and a copy of the report and appeal rights was provided to the administrator Ruby Garcia.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20220121155956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2023
Section Cited
CCR
80087(a)
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(a) The facility shall be clean, safe, sanitary, and in good repair at all times for the safety and well-being of all clients, employees, and visitors.

This regulations is not met as evidenced by:
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Administrator shall ensure that the restrooms bathtub is repaired and that the shower head and bath tub faucet run separately. Administrator is to send LPA photoraphic proof of repairs by the POC due date.
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Based on interview and observation, LPA found that the Jack-and-Jill style bathroom between rooms #128 and #130 have a rusted and moldy bathtub along with a showerhead and bathtub faucet that runs concurrently when turned on, which poses a potential health and safety risk to clients.
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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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6