198602244-9-3-2024-28-AS-RORN-D9MT64-20241001142629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 09/03/2024
Date Signed: 09/03/2024 02:52:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
08/26/2024 and conducted by Evaluator Sanjay Vaid

COMPLAINT CONTROL NUMBER: 28-AS-20240826174728

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: 84	DATE:	09/03/2024
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Ruby Garcia, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff member pushed resident in care.
Staff member prevented resident in care from accessing facility Activity Room.
Staff member spoke to resident in care in an aggressive manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) S Vaid conducted an unannounced initial 10 day complaint visit regarding the above allegations. LPA met Ruby Garcia, Administrator and explained the reason for the visit.

During today's visit, LPA reviewed and obtained resident and staff roster, requested, and obtained C1 face sheet, admissions agreement, physicians report and list of medications. LPA toured the physical plant with Administrator and did not observe any deficiencies or health and safety concerns. LPA Vaid interviewed Staff 1-6 (S1-S6). LPA interviewed residents 1-8 (R1-R8).

Regarding the allegation: Staff member pushed resident in care. It is alleged that staff pushed a resident in care. Six (6) out of (6) staff interviewed deny this allegation. Eight (8) out of (8) residents interviewed could not corroborate the allegation. The staff will redirect and de-escalate the issue, advise residents to remove their selves from the issue, and diffuse the issue, staff will not touch the residents, but only to help with assisted daily living. CONTINUED on 9099C........

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

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-20240826174728

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA ADULT LIVING CENTER	FACILITY NUMBER: 198602244
	VISIT DATE: 09/03/2024

NARRATIVE

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LPA Vaid interviewed R1, however R1 was not able to answer the questions asked. LPA observed R1 to be incoherent and disoriented when asked about the allegations made. Based on records obtained, observations made, and interviews conducted. 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 allegation is UNSUBSTANTIATED.

Regarding the allegation: Staff member prevented resident in care from accessing facility Activity Room. It is alleged that the staff did not allow a resident from using the activity room. Six (6) out of (6) staff interviewed deny this allegation. Eight (8) out of (8) residents interviewed could not corroborate the allegation. According to staff, the activities room is open to all the residents between the hours of 9am to 530 pm, the activity director will allow the residents to come into the activity room four (4) clients at a time due to the small area of the activity room. Other residents are told to wait outside and take turns when the activity room is occupied with four or more persons. On 07/10/24, the S3 had told R1 to remain calm and not to throw around the creamer and condiments in the activity room. R1 ignored the direction given and stormed off, slamming the door, and verbally assaulting other residents. S3 had told R1 they would not be able to use the activity room unless R1 was more respectful of other residents and staff. Based on records obtained, observations made, and interviews conducted. 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 allegation is UNSUBSTANTIATED.

Regarding the allegation: Staff member spoke to resident in care in an aggressive manner. It is alleged that staff spoke to residents in an aggressive manner. Six (6) out of (6) staff interviewed deny this allegation. Eight (8) out of (8) residents interviewed could not corroborate the allegation. S3 spoke to R1 on 07/10/24, in a firm tone. R1 was not listening to redirection given. After R1 started throwing around the condiments in the activity room, and verbally assaulting other residents. S3 spoke to R1 in firm tone and told them to leave the room. Based on records obtained, observations made, and interviews conducted. 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 allegation is UNSUBSTANTIATED.

An exit interview was conducted and copy of this report was given to Administrator Ruby Garcia.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC9099 (FAS) - (06/04)

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