198603286-9-19-2025-28-AS-DSIS-DM3TPA-20251002145401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 09/19/2025
Date Signed: 09/19/2025 02:18:36 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
08/27/2025 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250827141339

FACILITY NAME:	PASADENA VILLA SENIOR LIVING		FACILITY NUMBER:	198603286
ADMINISTRATOR:	MURPHY, MICHAEL		FACILITY TYPE:	740
ADDRESS:	1811 N. RAYMOND AVE		TELEPHONE:	(626) 791-6232
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	97	CENSUS: 58	DATE:	09/19/2025
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Bryanna Luke, Administrator		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Staff are not properly intervening between residents altercations

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Administrator, Bryanna Luke.

On 09/02/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA reviewed and requested copies of Resident #2 (R2), Resident #3 (R3), Resident #4 (R4's) file documents such as Face Sheet, Physician's Report, Admission Agreement, Appraisal Services and Needs Plan, House Rules, Personal Rights. LPA also obtained the Staff & Resident Roster, and staff in-service training document. LPA also interviewed Resident #1 (R1) to Resident #8 (R8), the Administrator, and Staff #1 (S1) to Staff #4 (S4).

On 09/15/2025, LPA obtained Special Incident Reports dated 08/28/2025 and 08/30/25 from the Administrator by fax.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

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 3

Control Number 28-AS-20250827141339

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 VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 09/19/2025

NARRATIVE

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During today's visit, LPA obtained the following documents: staff and resident rosters and documents from R1 to R4’s files. LPA interviewed Resident #9 (R9) to Resident #10 (R10). LPA re-interviewed R1, R2, and the Administrator.

The investigation revealed the following: in regard to the allegation "Staff are not properly intervening between residents’ altercations", it is alleged that R1 is being verbally harassed by R2 since June of 2025 with constant requests for favors, physical assistance, and money. It is also alleged that R2 also blocks R1's access to R1’s drawers and R2 makes loud noises when R1 is trying to sleep. R2 has also been observed in various stages of undress and has made unwanted sexual advances toward the R1. It is also alleged that R1 is sexually harassed by R3 and R4 by making unwanted sexual advances towards R1 since June 2025. R1 and three (3) out of ten (10) residents interviewed corroborated with the allegation but stated that inappropriate interactions were not reported to the staff. However, R1 and one (1) out of ten (10) residents stated that after the police visited the facility, R3 has stopped engaging in inappropriate interactions. R2 denied the allegations stating on not making unwanted sexual advances, verbally harassing R1, or asking to borrow money from R1. R3 and R4 interviewed both denied the allegations and stated never inappropriately touching nor making any inappropriate comments to R1 or other residents. LPA interviewed the Admin, and three (3) out of four (4) staff and stated that staff intervene, separate, and re-direct in residents’ altercations. The Administrator and three (3) out of four (4) staff interviewed did not witness R2, R3, or R4 verbally harass or make unwanted sexual advances towards R1. LPA received written documentation dated 8/21/2025 that R1 did not feel uncomfortable when interacting with R3 and the report indicated that R1 witnessed R3 touching another resident’s arm. Per administrator, R1 moved to a different room on 08/28/2025. Based on Special Incident Reports dated 8/28/2025 and 8/30/2025 indicates R4 being verbally aggressive and staff verbally warned R4. LPA interviewed the Administrator, three (3) out of four (4) staff are aware of R3 and R4 has made inappropriate comments and unwanted advances toward other residents. LPA received documentation dated 08/27/2025 in which it states to ensure resident safety, all management and staff are made aware of the incident regarding R3 who was placed on a 24-hour watch and provided additional staffing to ensure adequate supervision. To prevent further incidents, R3 has been lowered to 15-minute checks. Meeting with Management was also held with R3 and per Resident Care Director, R3 understands the severity of the situation. LPA requested documentation on staff training and Administrator provided in-service staff training conducted on 08/22/2025 on Abuse Reporting.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250827141339

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 VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 09/19/2025

NARRATIVE

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LPA asked the Administrator for documentation in R3 and R4’s files of any written warnings for making inappropriate behaviors and unwanted advances to other residents and violating House Rules or 30-Day eviction notices. Administrator provided a written warning dated 09/15/2025 which indicates R4 violating House Rules that continued violations may result in disciplinary action, up to and including discharge from the facility. Administrator also provided a written warning dated 09/15/2025 which indicates R3 violating House Rules that continued failure to respect personal boundaries may result in further action, including behavior contracts, meetings with facility leadership, or reconsideration of R3’s continued residency. Regarding issuing a 30-day eviction notice, Administrator stated that the facility is taking precautions actively communicating with R3 and R4’s Assisted Living Waiver Program Case Managers for guidance and ensuring that they have credible reasons to issue the 30-day eviction notice. At this time, Administrator believes that the facility should not issue a 30-day eviction notice to R3 and R4. There is not enough supportive evidence to concur with the reported allegation.

Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was held, and a copy of this report was provided to the Administrator, Bryanna Luke.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025

LIC9099 (FAS) - (06/04)

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