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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 09/01/2021
Date Signed: 09/01/2021 03:44:28 PM



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
08/03/2021 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20210803093535
FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 31DATE:
09/01/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Alexander SolorioTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Marijuana is present on the facility grounds


INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Nune Margaryan and Joe Katrdzhyan conducted a subsequent visit to the facility to further investigate the above noted allegation. Upon arriving at the facility, LPAs met with Administrator Alexander Solorio and explained the purpose of this visit.

The initial visit was conducted by LPAs Nune Margaryan and Tony Vasallo on 08/11/21. During the visit, LPAs obtained resident and staff roster, interviewed six (6) residents and six (6) staff. Resident #1's (R1) file was reviewed. On a later date additional phone interviews were conducted of three (3) staff. The following documents were also provided to LPA by email:
House Rules; Memo-Subject: Reminder of Designated smoking areas and Consequences for violation
Initial Training Records for staff; Non-Medical Medication: Polices, Procedures, Interaction of Drugs. MAR for Resident #1 (R1).

(Please see LIC 9099C for additional information)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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 5
Control Number 28-AS-20210803093535
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 VILLA SENIOR LIVING
FACILITY NUMBER: 198603286
VISIT DATE: 09/01/2021
NARRATIVE
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The investigation consisted of the following:

Based on interviews conducted, LPA learned that residents are smoking marijuana at the facility and staff admitted that there have been complaints regarding marijuana smell coming from the facility. During the visit conducted on 08/11/21, LPAs toured the facility and observed a strong odor of marijuana coming from room 45B and the nearby hallway area. Per staff, all residents are required to follow the facility house rules.

Based on LPA's observations and interviews which were conducted and documents reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D)

Exit interview conducted and report provided with Appeal rights.





SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20210803093535
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 VILLA SENIOR LIVING
FACILITY NUMBER: 198603286
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Administrator will review Title 22 Regulations Section 87468.1 on Personal Rights of Residents in All Facilities and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
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Based on interviews conducted, LPA learned that residents are smoking marijuana at the facility and staff admitted that there have been complaints regarding marijuana smell coming from the facility. During the visit conducted on 08/11/21, LPAs toured the facility and observed a strong odor of marijuana coming from room 45B and the nearby hallway area.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/03/2021 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20210803093535

FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 31DATE:
09/01/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Alexander SolorioTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff not qualified to administer medications
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Nune Margaryan and Joe Katrdzhyan conducted a subsequent visit to the facility to further investigate the above noted allegation. Upon arriving at the facility, LPAs met with Administrator Alexander Solorio and explained the purpose of this visit.

The initial visit was conducted by LPAs Nune Margaryan and Tony Vasallo on 08/11/21. During the visit, LPAs obtained resident and staff roster, interviewed six (6) residents and six (6) staff. Resident #1's (R1) file was reviewed. On a later date additional phone interviews were conducted of three (3) staff. The following documents were also provided to LPA by email:
House Rules; Memo-Subject: Reminder of Designated smoking areas and Consequences for violation
Initial Training Records for staff; Non-Medical Medication: Polices, Procedures, Interaction of Drugs. MAR for Resident #1 (R1).

(Please see LIC 9099C for additional information)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210803093535
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 VILLA SENIOR LIVING
FACILITY NUMBER: 198603286
VISIT DATE: 09/01/2021
NARRATIVE
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The investigation consisted of the following:

On 08/17/21, LPA Nune Margaryan spoke with the Administrator and requested verification of training for all staff who provide medications assistance. Documents were received and reviewed by the LPA and it was confirmed that staff working on the day of the reported incident had completed the required training to assist residents with medications. Based on interviews conducted, statements obtained from Staff members #1 and 2 (S1 and S2) confirmed that R1 never requested pain medication on the date of the incident and R1 has a history of refusing medications. Statements obtained from residents did not present concerns of medications not being administered as prescribed.

Although the allegation may have happened or is 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 and a copy of this report was provided to the Assistant Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5