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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602244
Report Date: 09/24/2021
Date Signed: 09/24/2021 03:16:59 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
05/13/2020 and conducted by Evaluator Nina Galarza
COMPLAINT CONTROL NUMBER: 28-AS-20200513143256
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: 97DATE:
09/24/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Clarissa Basto TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Client's behavior poses as a risk to other clients while in care
INVESTIGATION FINDINGS:
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On 9/24/2021 Licensing Program Analysts (LPAs) Nina Galarza and Nune Margaryan conducted a subsequent complaint visit for the allegation listed above, initially reported on 5/13/2020. On 5/15/2020 LPA P. Rivas conducted initial visit.

The investigation consisted of interviews with Staff 1 (S1), Staff 2 (S2), Clients 1 - 10 (C1-C10). On 9/24/2021 from 12 p.m. to 1 p.m., LPAs interviewed C1- C10. LPAs were unable to interview C11 and C12, for they were not present at the facility and both did not have a cell phone to be interviewed telephonically.

C1-C10 denied the allegation. C1-C10 stated they have never been harassed by other clients. C1-C10 stated they have never seen or heard of anyone being harassed. C1-C10 stated staff would address any concerns, including but not limited to harassment. C1-C10 stated they have not experienced behavior from another client that poses a risk. On 9/24/2021 from 1 p.m. to 1:15 p.m., LPAs interviewed S1 and S2. S1 and S2 denied the allegation. S1 and S2 stated they have not heard complaints from clients of harassment.
CONTINUED 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nina Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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-20200513143256
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: 09/24/2021
NARRATIVE
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S1 and S2 stated if they see a client without a shirt, they immediately address it and redirect client to put a shirt on.

LPAs requested copies of staff roster, resident roster, needs/appraisal plan and physicians report for C2, C11 and C12.

The investigation revealed the following, "Client's behavior poses as a risk to other clients while in care.":

(10) out of (10) clients interviewed denied the allegation. (10) out of (10) clients stated they have never been harassed by other clients. (10) out of (10) clients stated they have never seen or heard of anyone being harassed. (10) out of (10) clients stated staff would address any concerns, including but not limited to harassment. (10) out of (10) clients stated they have not experienced behavior from another client that poses a risk. (2) out of (2) staff denied the allegation. (2) out of (2) staff stated they have not heard complaints from clients of harassment. (2) out of (2) staff stated if they see a client without a shirt, they immediately address it and redirect client to put a shirt on.

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, a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nina Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2