198603286-10-23-2025-28-AS-DSIS-DNAVKK-20251110153028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 10/23/2025
Date Signed: 10/23/2025 04:47:59 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
10/20/2025 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251020094420

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: 59	DATE:	10/23/2025
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Bryanna Luke, Administrator		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Resident was not accorded dignity during an interaction with staff while in care.
Licensee did not ensure that resident had access to a call pendant while in care.
Licensee did not ensure that resident was provided a comfortable environment while in care.
Staff member did not accord privacy to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted a unannounced 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator, Bryanna Luke.

The investigation consisted of the following: LPA reviewed and requested copies of Resident #1 (R1) file documents such as Face Sheet, Physician's Report, Appraisal Services and Needs Plan. LPA also obtained the Staff & Resident Roster, and staff in-service training document. LPA also interviewed Resident #1 (R1) to Resident #6 (R6), the Administrator, and Staff #1 (S1) to Staff #4 (S4).

The investigation revealed the following: in regard to the allegation "Resident was not accorded dignity during an interaction with staff while in care", it is alleged that on 10/16/2025, S1 entered R1’s bedroom and pressed R1’s body in bed by climbing on top of R1 and put S1’s weight on R1 pressing hard on R1’s hip while reaching for R1’s controller that fell on the floor.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

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-20251020094420

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: 10/23/2025

NARRATIVE

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LPA interviewed R1 which corroborated the allegation by stating that R1 went on top of S1’s body pressing on R1’s hip. LPA interviewed five (5) out of six (6) residents that denied the allegation stating there have been no staff that have ever conducted in going over their bodies while in bed and have not witnessed any staff that ever went over another resident’s body while in bed. LPA interviewed S1 and S1 denied the allegation indicating that they never went on top of R1 during the incident. The Administrator and an additional three (3) out of three (3) staff denied the allegation stating that staff does not conduct unwanted touching and does not climb on top of resident’s bodies while resident is lying on the bed. Facility suspended S1 pending an internal investigation. S1 was suspended between 10/18/2025 to 10/20/2025 . S1 returned to work on 10/21/2025 as facility’s investigation did not reveal any evidence that this incident occurred between S1 and R1. There is not enough supportive evidence to concur with the reported allegation.

Allegation: “Licensee did not ensure that resident had access to a call pendant while in care”, it is alleged that S1 purposely dropped R1’s call pendant / remote and R1 was unable to retrieve it because it fell on the floor. LPA interviewed R1 did not corroborate the allegation stating that the remote for the bed accidentally fell while R1 was being changed and S1 helped pick it up. LPA confirmed that the remote is not a call pendant but rather a remote for the bed. LPA interviewed five (5) out of six (6) residents that denied the allegation stating on having access to call pendants. LPA interviewed the Administrator, four (4) out of four (4) staff that denied the allegation stating that all residents have access to call pendants. One (1) out of four (4) staff stated that the pendant was not dropped on purpose and it was accidentally dropped on the floor retrieved by the staff slightly moving the bed. There is not enough supportive evidence to concur with the reported allegation.

Allegation: “Licensee did not ensure that resident was provided a comfortable environment while in care” and “Staff member did not accord privacy to resident in care”, it is alleged that during the incident, S1 allegedly climbed on top of R1, S1 alleged removed all the clothing of R1. It is also alleged that R1 had to spend the night in cold temperatures. It is alleged that R1’s roommate was laughing at the interaction with S1 making R1 feel uncomfortable. LPA interviewed R1 who denied the allegation stating not being laughed from S1 and R1’s roommate during the interaction. LPA interviewed S1 that denied the allegations stating that R1 was changed and was not kept in the cold overnight. LPA also interviewed five (5) out of six (6) residents that also denied the allegation stating extra blankets are provided to help if it is cold.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20251020094420

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: 10/23/2025

NARRATIVE

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Six (6) out of six (6) residents also denied the allegation by stating that the staff accord privacy such as when being changed. LPA interviewed the Administrator, four (4) out of four (4) staff that denied the allegation stating that R1 was not kept overnight in cold temperatures. The Administrator and one (1) out of four (4) staff stated that R1 was changed and extra blankets were provided during cold temperatures. LPA toured the facility and observed extra blankets and linens in a locked storage area. The Administrator and four (4) out of four (4) staff also stated that they accord residents’ privacy when they are changing the residents by either closing the door or having that resident only in the room. Administrator and four (4) out of four (4) staff also stated that residents’ roommate are asked to briefly leave the room until the changing is done. LPA also reviewed records on Staff In-service training on Abuse Reporting in file. LPA also reviewed reports that the R1 will be provided care from a different care staff going forward. 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: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

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