198603286-12-12-2023-28-AS-RORN-CZBQ2Y-20240109104754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:51:38 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
12/09/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221209134534

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: 76	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	03:06 PM

ALLEGATION(S):

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Staff did not ensure the resident was accorded privacy during her phone conversation
Staff spoke inappropriately to resident in care
Facility staff harasses resident
Facility staff did not protect resident from being inappropriately touched by another resident
Resident’s hair was pulled by another resident due to lack of supervision
Facility staff did not safeguard resident’s belongings
Facility staff does not provide adequate amount of food
Facility staff does not serve nutritious meals
Facility staff does not follow food menu

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 12/14/2022, LPA obtained copies of staff & resident rosters, interviewed Assistant Administrator, Staff 1 (S1), Resident 1 - Resident 6 (R1 - R6) and toured the facility kitchen & dining room. LPA reviewed surveillance video of the incident involving R1 and R2. Copies of R1's appraisal/needs and service plans, R1's incident reports, facility's house rules, and December 2022 menu & alternative menu were obtained and reviewed. Today's visit, LPA obtained copies of staff & resident rosters, interviewed Staff 2 - Staff 3 (S2 - S3), Resident 7 - Resident 8 (R7 - R8) and toured the dining room during lunch time.

(Continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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-20221209134534

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: 12/12/2023

NARRATIVE

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The investigation revealed the following:

Regarding the allegation "staff did not ensure the resident was accorded privacy during her phone conversation", it is alleged that the Assistant Administrator eavesdrop on a Resident 1 (R1) calls with the ombudsman. Assistant Administrator and staff denied the allegation. Residents interviewed could not corroborate the allegation.

Regarding the allegation "staff spoke inappropriately to resident in care" and "facility staff harasses resident", it is alleged that a staff belittles, stares down, gives evil looks, and intimidates Resident 1 (R1). Assistant Administrator and staff denied the allegations. Residents interviewed could not corroborate the allegations and 3 residents stated that R1 was the one insulting and harassing the staff.

Regarding the allegation "facility staff did not protect resident from being inappropriately touched by another resident", it is alleged that Resident 3 (R3) inappropriately touches Resident 1 (R1). Assistant Administrator and staff denied the allegation. R3 denied the allegation and stated that R1 falsely accuses R3 whenever R3 does not get R1 alcohol. Residents interviewed could not corroborate the allegation and 2 residents stated that R1 mistreats and harasses R3.

Regarding the allegation "resident’s hair was pulled by another resident due to lack of supervision", it is alleged that Resident 2 (R2) pulled Resident 3 (R3) hair for no reason and staff did nothing. Assistant Administrator showed the LPA a video footage of the incident with a date and time of 10/09/2022 at 9:58pm. According to the surveillance video, a staff is observed escorting R1 back to the room in a wheelchair. At the same time, R2 is observed coming in the direction of R1 (from the opposite side) also in a wheelchair. R2 is observed suddenly reaching over with the right hand and pulling the hair of R1. The staff is observed immediately intervening and breaking up the incident and separating both residents. After the incident, the staff is observed continuing to escort R1 back to the room. Although the incident did occur, R2's action was so sudden and unpredictable for the staff to prevent the incident from happening, but the staff quickly intervened and prevented the fight from escalating. This allegation was previously investigated in complaint control number 28-AS-20221014123935 and the allegation was found unsubstantiated.

(Continued to LIC 9099-C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20221209134534

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: 12/12/2023

NARRATIVE

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Regarding the allegation "facility staff did not safeguard resident’s belongings", it is alleged that Resident 1 (R1) personal belongings were stolen from R1's room. Assistant Administrator and staff denied the allegation. Residents interviewed could not corroborate the allegation.

Regarding the allegation "facility staff does not provide adequate amount of food", "facility staff does not serve nutritious meals" and "facility staff does not follow food menu", it is alleged that the facility does not serve enough food to the residents, the food is not healthy because it is all carbs, and the menu is not being followed. Assistant Administrator and staff denied the allegations. Staff 1 (S1) who is the cook stated that an adequate amount of food is served and they follow a menu created by a certified nutritionist. Their food contains proteins, carbs and veggies. The residents are notified in a timely manner if there are any modifications to the menu to give them a chance to decide if they want to order something from the alternative menu. Residents interviewed could not corroborate the allegations. During the tours of the kitchen and dining room, the LPA observed an adequate amount of food being served that consisted of proteins, carbs and veggies.

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 the report was provided

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

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