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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 06/26/2026
Date Signed: 06/26/2026 02:58:30 PM

Substantiated


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
06/16/2026 and conducted by Evaluator Mayra Cota
COMPLAINT CONTROL NUMBER: 28-AS-20260616170020
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: 71DATE:
06/26/2026
UNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Ruby Garcia, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent complaint investigation visit regarding the above-mentioned allegations. LPA met with Ruby Garcia, and the reason for the visit was explained.
The investigation consisted of the following:

Initial 10-day visit was conducted by LPA Margaryan on 6/25/2026 in which copies of staff and resident rosters were obtained. During today’s visit, LPA Cota, obtained copies of staff and resident rosters, toured the facility, inspected resident and general facility bathrooms and interviewed Staff 1- Staff 6 (S1-S6) and Resident 1 – Resident 7 (R1-R7). LPA also reviewed R1’s medication and June 2026 MAR.

The investigation revealed the following: ****Continues on LIC 9099-C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
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
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
06/16/2026 and conducted by Evaluator Mayra Cota
COMPLAINT CONTROL NUMBER: 28-AS-20260616170020

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: 71DATE:
06/26/2026
UNANNOUNCEDTIME BEGAN:
07:30 AM
MET WITH:Ruby Garcia, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not provide adequate bathroom facilities for resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent complaint investigation visit regarding the above-mentioned allegations. LPA met with Ruby Garcia, and the reason for the visit was explained.
The investigation consisted of the following:

Initial 10-day visit was conducted by LPA Margaryan on 6/25/2026 in which copies of staff and resident rosters were obtained. During today’s visit, LPA Cota, obtained copies of staff and resident rosters, toured the facility, inspected resident and general facility bathrooms and interviewed Staff 1- Staff 6 (S1-S6) and Resident 1 – Resident 7 (R1-R7). LPA also reviewed R1’s medication and June 2026 MAR.

The investigation revealed the following: ****Continues on LIC 9099-C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20260616170020
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: 06/26/2026
NARRATIVE
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Regarding: Staff does not provide adequate bathroom facilities for resident in care.

It is alleged that resident is being “blocked” from accessing the bathroom in their room due to other resident frequently being in the bathroom and that there are no additional bathrooms for resident to use. It is also alleged that resident has to urinate in a jar and in the trashcan due to not having access to the bathroom.

Staff deny the allegation. Interviews with (4) out of (4) staff indicated that residents do not block residents from accessing their bathrooms. Staff indicated that the facility has additional bathrooms for residents to use in case the bathroom in their room is busy. The facility has three extra gender-neutral bathrooms located on the first-floor hallway by the patio, at the end of the hallway (north) on the second floor and in the staff office. Staff stated that the extra bathrooms are accessible to residents upon request. Staff keep the extra bathrooms locked to ensure safety; however, keys are always available for staff to open the bathrooms when residents need to use them. Interviews with (6) out of (7) residents revealed that they have no issues with the accessibility to their bathroom. Residents also stated that the hallway bathrooms are available if they need to use them. During tour of the facility, LPA observed two hallway bathrooms with general access and an additional bathroom in the main office of the facility. Interviews and observations could not corroborate the allegation that staff does not provide adequate bathroom facilities for residents in care.



Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Ruby Garcia, and a copy of this report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20260616170020
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: 06/26/2026
NARRATIVE
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Regarding: Staff mismanaged resident's medication.

It is alleged that on 6/16/2026, resident did not receive their dinner medications and that they were given the wrong pills which were different in color than what they typically receive.

Interview with S1 indicated that the facility did not get a visit from the police on 6/16/2026; however; S1 confirmed that on 6/24/2026, the police visited the facility and spoke to S2 who came in to work at 8:00 p.m. and talked directly to the police. Interview with S2 revealed that on 6/24/2026, the police visited the facility at approximately 9:30 p.m. in response to a report from R1 alleging that they received the wrong evening medication from staff. S2 indicated that the police handed S2, two (2) oblong green pills which police said were given to them by R1 during their interview with R1 to obtain additional information regarding the incident. Interviews with S1 – S4 could not confirm if the medication came from the facility nor, which staff could have provided R1 with the green pills. Furthermore, R1 could not provide specific details as to which staff member gave them the two (2) green pills. However, S2 confirmed during interview that the correct medication was given to R1 by S2 after 9:30 p.m. on 6/24/2026, which is outside of the medication administration window of 4:30 – 6:00 p.m. in which R1 receives their evening dosage. S2 indicated that when reviewing S2’s evening medications the noticed that R1’s medication had not been given to them and proceeded to administer. Interview with S3 further indicated that they did not give R1 their evening medication on 6/24/2024; however, review of June 2026 MAR log by LPA revealed that evening medication was incorrectly documented as given to R1 by S3.

Although the information obtained cannot corroborate if R1 was given the wrong medication by staff, interviews and record review corroborate that R1’s medication was mismanaged by staff due to R1 not receiving their evening medication on time and by staff incorrectly documenting evening medication administration on 6/24/2026.

The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted with Ruby Garcia, and a copy of this report was provided

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20260616170020
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2026
Section Cited
CCR
80075(b)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met evidenced by:
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Administrator will submit to LPA, written Plan of Correction, proof of staff training and a copy of Medication Administration Policy/Procedures by POC due date.
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S2 indicated that R1 received their evening medication after 9:30 p.m. on 6/24/2026, which is outside of the medication administration window of 4:30 – 6:00 p.m. in which R1 receives their evening dosage. Also, review of June 2026 MAR log by revealed that evening medication was incorrectly documented as given to R1 by S3 on 6/24/2026.
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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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5