198602536-8-9-2024-28-AS-TVAO-D83UKG-20240812153902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602536
Report Date: 08/08/2024
Date Signed: 08/09/2024 09:13:58 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/12/2023 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230112144051

FACILITY NAME:	SVS PASADENA		FACILITY NUMBER:	198602536
ADMINISTRATOR:	NANONG-YRIGOYEN, KIMBERLY		FACILITY TYPE:	775
ADDRESS:	180 N VINEDO AVE		TELEPHONE:	(626) 773-7254
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	75	CENSUS: 58	DATE:	08/08/2024
		UNANNOUNCED	TIME BEGAN:	02:59 PM
MET WITH:	Administrator Kimberly Nanong-Yrigoyen		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff failed to seek medical attention in a timely manner.
Lack of supervision resulting in client sustaining unexplained injury.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

*This is a corrected version of previously dated report 8/8/24. No changes to findings.*Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced visit on 08/08/2024, to deliver findings. Subsequent complaint investigation was conducted on 7/9/2024 and needs further investigation was needed. Initial complaint investigation visit was conducted by LPA Rea on 01/19/2023 and needs further investigation was documented. LPA Ramirez was met by Administrator Kimberly Nanong-Yrigoyen and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Copies of Staff#4-5 (S4-S5) Employment Application, Annual Personal Information Update, First Aid/CPR certificate, Interview of Staff# 1-5 (S1-S5), Interview of C1's responsible party, Attempted Interview of C1 and C2, Copies of client#1(C1) Physician’s report, face sheet, Individual Program Plan (IPP), Copy of client#2 (C2) Face sheet, Individual Program Plan (IPP), Pasadena Police Report 2023-2971, and physical plant tour.
See 9099-C

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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-20230112144051

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SVS PASADENA	FACILITY NUMBER: 198602536
	VISIT DATE: 08/08/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following. Regarding Allegation(s): Facility staff failed to seek medical attention in a timely manner- It is alleged that facility staff failed to seek medical attention for C1 on 01/05/2023. Interview of S3 and S4 revealed, C1 was picked up from their home and arrived at the facility around 9am. C1 walked into the facility and did not show symptoms of distress or illness. Around 9:25am S3, S4, C1 and C2 proceeded into the facility arts and crafts room. At 9:29am C1 was observed by S3 and S4 to be seated in the facility chair holding their cellphone in one hand. C1 suddenly tensed into a plank form and S3 and S4 rushed over to assist C1 to the ground. According to S3 and S4, they believed C1 was experiencing a seizure. According to written statement, C1’s responsible party was alerted of C1 new onset seizure. Written statement from S2 revealed, S6 offered to take C1 to urgent care but C1’s responsible party denied and said C1’s mom was on her way to pick up C1. Interview of C1’s responsible party revealed they were contacted by staff around 9:35am to 9:45am and informed that C1 had suffered a small seizure and needed to be picked up. C1’s responsible party revealed they informed S6 that C1’s mom would come pick up C1 and take C1 home. Although staff did not call 911, staff did assess C1 and per their assessment, C1 was assisted to a wheelchair and C1’s responsible party was contacted to pick C1 up. During record review of S3 and S3, LPA Ramirez verified S3 and S4 are up to date on their CPR/First Aid training. Five (5) out of the five (5) staff interviewed deny this allegation. Due to C1 and C2 being limited verbal, LPA Ramirez was unable to interview C1 and C2. Pasadena police report 2023-2971, revealed this case is closed pending further discovery of information or evidence that depicts a crime occurred. Although the allegation 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 allegations are UNSUBSTANTIATED.

Lack of supervision resulting in client sustaining unexplained injury- It is alleged C1 sustained an unexplained injury on 1/5/2023, because of lack of supervision at the facility. Review of C1’s medical records revealed C1 did suffer an injury on 01/05/2023. There was no indication on C1’s medical records that revealed C1 sustained this injury because of negligence or lack of supervision. Pasadena police report 2023-2971, revealed this case is closed pending further discovery of information or evidence that depicts a crime occurred. Five (5) out of the five (5) staff interviewed deny this allegation. Due to C1 and C2 being limited verbal, LPA Ramirez was unable to interview C1 and C2. Although the allegation 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 allegations are UNSUBSTANTIATED.

No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2