198603286-11-30-2023-28-AS-RORN-CZCNZP-20240110095440

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 11/30/2023
Date Signed: 11/30/2023 04:37:22 PM

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
11/29/2023 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231129083238

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: 78	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Maria "Luisa" Razo		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff does prevent the spread of lice.
Staff does not ensure resident's bathing needs are being met.
Resident has threatened another resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit in response to the above allegations. LPA met with Maria “Luisa” Razo (Resident Care Director) and discussed the purpose of today's visit.

The investigation consisted of the following:

During today's visit, LPA interviewed Staff members 1 - 5 (S1 - S3) and Residents 1-10 (R1 – R10). Reviewed R2’s file and obtained copies of R2’s Physician Report, Shower/Bedding Schedule, Staff Roster, and Resident Roster.

(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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-20231129083238

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: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 11/30/2023

NARRATIVE

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The investigation revealed the following:

Allegation: Staff does prevent the spread of lice.
It is alleged that there is an outbreak of lice at the facility, its alleged that R2 has lice and facility has done nothing to address this issue. Interviews with Staff, 5 out of 5 Staff denied the above allegation and stated that they have not received complaints from residents regarding lice or itching. 5 out of 5 staff stated that if there is ever a resident with lice they follow procedures with disinfecting, cleaning, treating the residents with lice and checking all other residents for lice. Interviews with residents, 9 out of 10 residents denied the above allegation and stated they do not have lice nor have they heard anything about other residents at the facility having lice.

Allegation: Staff does not ensure resident's bathing needs are being met.
It is alleged that R2 does not bathe, and facility is not doing anything to ensure the resident’s bathing needs are being addressed and met. LPA reviewed R2’s file and it revealed that R2 does need assistance with bathing. There is a Shower Schedule that the facility follows and R2 is provided with assistance in bathing twice weekly. Interviews with staff 3 out of 5 staff stated that although they have to remind R2 about showering R2 is compliant with showers and is being provided with assistance with bathing. LPA reviewed forms of residents who refuse to shower and R2 was not a resident listed as non-compliant. Interviews with residents 9 out of 10 residents denied the above allegation and stated that they are provided with showering/bathing needs and have a scheduled date 2-3 times weekly where they shower. Of the residents that need assistance with bathing each stated that they are provided with the assistance and are showered regularly. Interview with R2, resident stated they bathe at facility twice weekly and at their families home once weekly. LPA observed R2 and R2 was with clean clothing, face and hands clean and appeared well groomed.

(Continued on 9099-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20231129083238

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: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 11/30/2023

NARRATIVE

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Allegation: Resident has threatened another resident in care.
It is alleged that R2 threatened R3, destroyed their personal belongings and has threatened them. Interviews with staff 5 out of 5 staff stated that R2 is not aggressive and have not heard of R2 having altercations with other residents. S4 stated that on one occasion R2 did have a disagreement with roommate but this incident did not become aggressive and was addressed in a timely manner and R2 was located to a different room to avoid further issues by the next day. Interviews with residents 8 out of 10 residents stated that they have not had any altercations with other residents, have never had their personal property destroyed by another resident and feel safe at facility. During interview with R3, resident denied allegation and stated that they have never been in an altercation with another resident and have never had their belongings destroyed by anyone while at the facility.

Based on statements and interviews conducted with Staff and residents, and review of residents files, there was not enough supportive evidence to concur with the reported allegation. Although the allegations 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 held, and a copy of this report was provided to Luisa Razo.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

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