198603286-10-20-2023-28-AS-FFIS-CZARQX-20240108121418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 10/20/2023
Date Signed: 10/20/2023 12:27:40 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: 74	DATE:	10/20/2023
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Assistant Administrator -Alexander ' Alex' Solorio		TIME COMPLETED:	12:30 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 a subsequent unannounced complaint visit regarding the allegations listed above. This licensing report supersedes the licensing report dated 3/27/23. LPA met with Assistant Administrator Alexander Solorio and discussed the purpose of today's visit. Findings remain the same.

During visit conducted on 3/27/23, LPA obtained a copy of the resident roster, staff roster, Resident #1 (R1's) file and obtained relevant documentation: R1's Face Sheet, 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 and R6) and interviewed Resident #2-5 and #7 (R2-R5 and R7). CONTINUATION ON 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: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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-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: 10/20/2023

NARRATIVE

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LPA Calderon attempt to interview via telephonically R1's Psychiatric Social Worker and LPA via telephonically interviewed R1's Clinical Program Manager from Worker Office of Diversion of Reentry.

On 10/20/23 LPA Calderon toured random resident bedrooms: Room’s #4, 6, 18, 39 and 44 to check call light button pendants and redelivered report.

Regarding Allegation: Resident's room has no call light. LPA Calderon interview with staff revealed that (5) out of (5) call light buttons are distributed to residents based on their needs; facility uses call pendent buttons. Interviews with (3) out of (5) staff informed LPA Calderon that R1 has a call button pendant. LPA Calderon reviewed R1's call button pendant agreement documentation which stated R1 received a call button pendant. R1 refused to show LPA call button pendant when R1’s room tour was conducted. LPA observed random rooms for call button pendants and residents in rooms # 4,6,18,39 and 44 all had call light buttons /pendants, either on a string or on the wall near bed.

Regarding Allegation: Resident's needs are not being met by staff. LPA Calderon interviewed staff, (5) out of (5) staff denied the above allegations, staff informed LPA residents and R1 are receiving services to meet their needs. (5) out of (5) staff during interview with LPA stated R1 does not have a prescription order for bed rails, staff provide laundry service, food service, transportation when needed and medical services when required. Staff stated R1 at times refuses assistance provided by staff and medical professionals and R1 is an independent individual. LPA interviewed R2-R5 and R7 all denied the above allegation and stated they are assisted by staff to meet their needs and staff clean, do laundry and provide meals. During telephone interview with Clinical Program Manager for R1 informed LPA R1 refuses assistance and services offered to R1 to assist with their needs, facility support R1, R1’s medical team is involved with R1 and R1 does not allow assistance. LPA observed R1’s bedroom and observed no half/full bed rails in R1’s bed. LPA reviewed R1’s file, physician report states R1 is not on Hospice, no bed rail order was noted in R1’s file and R1’s Appraisal/Needs and Service Plan states R1 is independent with all Activities of Daily Living.

CONTINUATION ON 9099-C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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: 10/20/2023

NARRATIVE

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Regarding Allegation: Staff is not treating resident with dignity. LPA Calderon interviewed staff Assistant Administrator and staff S1-S4, staff denied allegation stating all residents are treated with dignity and respect and are do not treated any residents differently. LPA Calderon interviewed residents, R2-R5 and R7 whom denied the above allegation stating staff treat them with dignity and respect and have not observed staff treating residents disrespectfully. During telephone interview with Clinical Program Manager for R1 informed LPA: not having concerns with how staff treat residents and R1 as they’ve observed staff treat residents with dignity and respect, facility is diligent, clean space, and knowledgeable.

Regarding Allegation: Staff are retaliating against resident. LPA Calderon interviewed staff Assistant Administrator, S1-S4, staff 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 denied the above allegation and informed LPA Calderon staff do not retaliate against them or other residents. During telephone interview with Clinical Program Manager for R1 informed LPA staff does not retaliate against R1.

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: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC9099 (FAS) - (06/04)

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