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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 01/26/2024
Date Signed: 01/26/2024 03:53:18 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
01/18/2024 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20240118141403
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: 85DATE:
01/26/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator Ruby Garcia TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Client alleges facility owes them 1 million dollars.
INVESTIGATION FINDINGS:
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On 1/26/2024 at 12: 00 p.m., Licensing Program Analyst(s) (LPAs) Jewel Baptiste and Nicol Wesley conducted an unannounced complaint investigation for the allegation(s) listed above. LPAs met with Administrator Ruby Garcia and the purpose of the visit was discussed.

During today’s visit LPAs interviewed the administrator and a total of three (3) staff, whom shall be referred to as Staff #1-#3 (S1-S3). LPAs also interviewed a total of eight (8) clients, whom shall be referred to as clients #1-#8 (C1-C8). LPAs collected a copy of the staff and client roster. LPA’s reviewed C1's file and collected copies of C1's ID and Emergency Information, Physicians Report, Needs and Services Plan, Preplacement appraisal, Physician progress notes, Admissions agreement and an incident report dated 5/3/2021 and 5/23/2023.

Report Continued 9099c
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
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 2
Control Number 28-AS-20240118141403
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: 01/26/2024
NARRATIVE
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The investigation revealed the following: Regarding “Client alleges facility owes them 1 million dollars”. It is alleged that staff owes C1 one (1) million dollars and C2 knocked on C1’s door without a shirt. The administrator denied the allegation stating, the facility does not handle C1’s finances and they have never witness C2 without a shirt. 3 out of 3 staff denied the allegation and has never witness C2 without clothing. During the interview with C1, they were unable to state why the facility owed a million dollars. During the interview with C2 they denied walking around the facility without a shirt. 7 out of 8 residents did not corroborate the allegation. Based on interviews, observations and file review conducted, there was not enough supportive evidence to corroborate the allegation.

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 is UNSUBSTANTIATED.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2