198603286-3-27-2023-28-AS-FFIS-CZARQY-20240108121418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:20:18 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
03/24/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230324105203

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: 69	DATE:	03/27/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Assistant Administrator -Alexander ' Alex' Solorio		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Resident's room has no call light.
Resident's needs are not being met by staff.
Staff is not treating resident with dignity.
Staff are retaliating against resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with Alexander Solorio and discussed the purpose of today's visit.

During this visit, LPA obtained a copy of the resident roster, staff roster, Resident #1 (R1's) file and obtained relevant documentation: R1's FaceSheet, R1's Physician Report, R1's Medical Consent Form, Pre-Placement Appraisal Information, R1's Appraisal, R1's Care Plan, R1's Appraisal/Needs and Service Plan Special Incident Reports,R1's Medical Refusal, Email with R1's Psychiatric Social Worker and Clinical Program Manager, R1's Behavior Contract, R1's Call Button Pendant Agreement. Fire Alarm Notice. LPA toured common areas and R1's bedroom. LPA interviewed Assistant Administrator Alex, Staff #1-4 (S1-S4), attempt interview with Resident#1 and #6 (R1 andR6) and interviewed Resident #2-5 and #7 (R2-R5 and R7), attempt to interview R1's Psychiatric Social Worker and interviewed R1's Clinical Program Manager via telephonically.

Continuation on LIC 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230324105203

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: 03/27/2023

NARRATIVE

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Regarding Allegation: Resident's room has no call light. LPA Calderon interviewed staff Alex, S1-S4 stated that residents usually who have restrictions and are bedridden are ones with call button pendants. Alex, S2 and S3 stated R1 has a call button pendant. LPA Calderon observation when touring facility, building is a one story building, does not have separate floors or units. LPA Calderon reviewed R1's call button pendant Agreement stated responsibilities when receiving a pendant.

Regarding Allegation: Resident's needs are not being met by staff. LPA Calderom interview staff Alex, S1-S4 all denied above allegations stating residents are receiving services to met their needs. Staff provide laundry service, food service, transportation when needed and medical services when required. Staff all stated R1 at times refuses help by staff as R1 is independent. LPA interviewed R2-R5 and R7 all denied allegation and stated they are assisted by staff to met their needs like staff clean, do laundry and provide meals.

Regarding Allegation: Staff is not treating resident with dignity. LPA Calderon interviewed staff Alex and S1-S4 all denied allegation stating all residents are treated with dignity and respect and are do not treated any different. LPA Calderon interviewed R2-R5 and R7 and denied above allegation stating staff treat them with dignity and respect and have not observed staff treating residents disrespectfully.

Regarding Allegation: Staff are retaliating against resident. LPA Calderon interviewed Staff Alex, S1-S4 all denied above allegation stating they do not retaliate and they respect and treat residents the same, staff talk calm and talk with residents. LPA interviewed R2-R5 and R7 stating staff do not retaliate against them or other residents.

Although the allegation(s) 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.

Exit interview was conducted and a copy of this report was provided to Alexander Solorio/Assistant Administrator

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC9099 (FAS) - (06/04)

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