198603286-1-5-2024-28-AS-RORN-CZBM9E-20240109082435

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 01/05/2024
Date Signed: 01/05/2024 03:21:30 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
05/26/2023 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230526075044

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:	01/05/2024
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff did not prevent an altercation between residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit regarding the above allegation. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit

The investigation consisted of the following: During today's visit LPA toured facility, dining room, various resident bedrooms, and obtained copies of resident and staff rosters, copy of Incident Report Regarding Altercation between R1 and R2, Behavior Contract for R1 and conducted interviews with 7 Residents (R1-R7) and 5 Staff (S1-S5).

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: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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-20230526075044

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: 01/05/2024

NARRATIVE

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The investigation revealed the following:

Allegation: Facility staff did not prevent an altercation between residents.
It is alleged that facility staff did not prevent R1 and R2 from being involved in a verbal altercation that then turned physical.
LPA reviewed incident report pertaining to the above allegation along with the report of suspected dependent / elder abuse, incident report indicated that authorities were called, no injuries were reported and both parties were left in the care of the facility. Note from authorities indicated the same observation. Interviews with Residents 7 out of 7 residents denied the above allegation and stated that staff try there best efforts to de-escalate altercations and will speak with each resident to mediate the situation until both parties have calmed down. 4 out of 7 residents indicated that staff will relocate a resident if needed to ensure distance and safety of residents. During interview with R1 it was stated that they cannot remember exactly why they threw coffee at R2 but are sure it was because R2 made an inappropriate comment while passing by R1. R1 further stated that R2 pushed them and staff separated the two parties. Interview with R2 stated that they recall the situation, staff separated both parties and the authorities arrived, R2 stated that they refused to press charges against R1. Both R1 and R2 stated that they have since been separated and have no longer had any other altercations and do not speak to one another. During tour, LPA observed R1 and R2 sitting at separate tables on opposite ends of the dining area during breakfast. Interviews with Staff 5 out of 5 Staff denied the above allegation and stated that when they hear residents begin to argue they will speak to the residents, separate them and de-escalate the situation, a report will be made to management and they will then mediate the situation explaining the house rules that each party agreed upon and find a way to keep both parties safe and content.

Based on statements and interviews conducted with staff and residents, review resident records, there was not enough supportive evidence to concur with the reported allegations.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to Alexander Solorio.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

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