198602244-8-19-2021-28-AS-LHIS-C6VPMM-20210915112634

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 08/18/2021
Date Signed: 08/19/2021 01:50:41 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
08/11/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210811134815

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: 100	DATE:	08/18/2021
		UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Ruby Garcia, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff hit client.
Lack of supervision resulting in residents engaging in altercations.
Staff failed to provide a safe and comfortable environment for resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegations. The purpose of the visit was discussed with Medication Supervisor. Administrator Ruby Garcia arrived shortly after.

The investigation consisted of the following: A tour of the interior and exterior physical plant was conducted. No altercations between residents were observed during lunch dining service. Client (C1's) room was inspected. No health and safety issues were observed. Clients (C1- C10) and staff (S1- S7) were interviewed. Prototype/ DMH-Full Service Partnership case manager was interviewed. Copies of Client (C1's) file documents [Preplacement Appraisal, Face Sheet, Physician's Report, Functional Capability Assessment, Appraisal Needs and Services Plan, Medication Administration Records, Admission Agreement, incident reports] client roster and LIC 500 Personnel Report were obtained and reviewed.

See LIC 9099C for continutation of report.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

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-20210811134815

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: 08/18/2021

NARRATIVE

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Allegation: "Staff hit client." Based on interviews conducted a physical altercation incident between client (C1) and staff (S1) occurred on January 20, 2021. Client (C1) became agitated when staff (S1) instructed client to put on a surgical mask in order to adhere to COVID-19 public health recommendations. According to interviews, client (C1) was observed being combative with staff (S1). The incident began outside C1's room door and then proceeded inside C1's room. Staff (S1) stated that C1 threw a glass bottle at the staff. Client (C2) witnessed the incident and stated that C1 was combative with staff (S1). Client (C2) stated that staff (S1) was on top of client (C1) in attempt to restrain the combative client. Administrator and staff (S7) responded to the incident and called 911. Client (C1) bit staff (S1's) finger, and scratched the staff's face. One (1) out of (10) clients observed the physical altercation but did not observe staff (S1) hit client (C1). All staff interviewed denied that staff hit client, and stated that client (C1) is very aggressive towards all clients in care and staff. According to file review and interviews conducted client (C1) has refused to take medications, which have resulted in an increase in aggressive behaviors towards other clients on a daily basis.

Allegation: "Lack of supervision resulting in residents engaging in altercations." According to interviews conducted and information obtained during day shift there are 3 office staff [Administrator, Medication Supervisor, and Activities Director] 2 direct caregivers, 4 housekeepers, and 5 kitchen staff. The PM shift starts at 4:00 pm -12:30 am. There is 1 med-tech, 2 caregivers, and 2 kitchen staff. The night shift has 1 med-tech, 1 caregiver, and 1 direct care staff that provides security watch that leaves at 12:30 AM. Five (5) out of 10 clients stated there is lack of supervision especially during the night time shift.

Seven (7) out of 7 staff stated there is adequate supervision. Staff check clients every 2 hours during all shifts, and when altercations between clients occur they immediately respond and redirect clients. According to client and staff interviews, client (C1) regularly accuses other clients of harassment and engages in verbal altercations with both clients and staff. On 7/28/21 and 8/9/21 client (C1) and (C10) were involved in verbal altercations. On 7/28/21, C1 accused C10 of harassment and called the police department. On 8/9/2021, both C1 and C10 argued in the dining room because C1 cut in front of the lunch line and reached over C10 to grab food. Client (C10) stated that client (C1) made threats and became verbally aggressive. Kitchen staff were present during the incident, and administrative staff responded immediately. Based on information obtained there is insufficient evidence to prove this allegation.

See LIC 9099C for continuation of report.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210811134815

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: 08/18/2021

NARRATIVE

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Allegation: "Staff failed to provide a safe and comfortable environment for resident while in care." Based on observations made and interviews conducted the findings indicate clients in care are provided a clean, and relatively safe environment. Five (5) out 10 clients stated they do not feel safe because there are some mentally disabled clients with aggressive behaviors that worry them. They also reported that during late at night outsiders have attempted to enter the facility in the past. All clients stated their rooms, and the physical plant is comfortable. All staff stated clients are afforded a safe and comfortable environment. Staff stated they provide supervision and try to be accommodating to clients. There is one (1) direct care staff that works the night shift, whose responsibilities include facility security. Resident room doors were observed to have working locks. The facility has surveillance of common areas. During the physical plant inspection no safety issues were observed.

Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED.

An exit interview was held with Administrator Ruby Garcia. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC9099 (FAS) - (06/04)

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