198603286-9-12-2023-28-AS-RORN-CZJM4V-20240116081721

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 09/12/2023
Date Signed: 09/12/2023 02:18:03 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
09/08/2023 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230908142831

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:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Alexander Solorio		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide adequate supervision resulting in resident eloping from facility

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Assistant Administrator Alexander Solorio, Staff 1-3 (S1-3) and Residents 1-7 (R1-7). R7 was not interviewed as resident was not at the facility at the time of the visit. LPA collected copies of Staff and Resident Rosters. LPA reviewed R7's facility file and collected copies of documents relevant to the investigation. LPA also collected a copy of Unusual Incident/ Injury Report dated 09/07/23 and Facility Sign Out Sheet for dates 09/02/23 - 09/12/23.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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 2

Control Number 28-AS-20230908142831

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: 09/12/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Investigation revealed the following: Regarding allegation, Staff did not provide adequate supervision resulting in resident eloping from facility, it is alleged that on 09/05/23 at approximately 8am, a resident left the facility on their own and did not advise facility staff where they were going and has not returned since. Interviews conducted with Assistant Administrator and S1-3 revealed that there is always enough staff on schedule everyday to provide adequate supervision for facility residents. Staff stated that there are many residents that are able to leave the facility unassisted and they just have to sign in and out. Interview conducted with Assistant Administrator revealed that R7 recently moved into the facility and is able to leave the facility unassisted. He stated that R7 did leave the facility on 09/05/23 and did not inform any staff. He stated that staff made the appropriate reports to CCLD, LTCO and Pasadena Police Department. Assistant Administrator stated that he also submitted the SOC341 as this resident had not left the facility before without first signing out. He stated that R7 did return to the facility on 09/08/23 and reported to staff that they had been visiting with family. LPA also reviewed Unusual Incident/ Injury Report dated 9/07/23 which is reporting the above referenced incident and notifying CCLD of what occurred. Assistant Administrator denied that the facility does not provide adequate supervision. He stated that he always ensures that the facility is fully staffed to provide proper care and supervision to facility residents. He stated that there is always someone in the front desk as that is where residents have to go when exiting the facility. Interviews conducted with 6 out of 7 residents revealed that they believe there are enough staff on schedule to provide adequate supervision. R7 was not interviewed as they were not at the facility during the visit.

During the time of the visit, LPA observed that there were enough staff on schedule. LPA reviewed R7's Physician's Report for Residential Care Facilities for the Elderly (RCFE) and observed that R7 is able to leave the facility unassisted. LPA also observed that the proper reporting was done by facility staff as well as proper follow up calls upon resident's return to the facility. LPA reviewed Facility Personnel Report (LIC500) which revealed that the facility is properly staffed to oversee and care for the residents in placement. LPA additionally reviewed Resident Sign out sheet and observed that R7 signed out on 09/12/23. Based on statements gathered from interviews conducted with staff, residents and LPA review of documents, there was not enough supportive evidence to concur with the reported allegation.

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. A copy of the report was provided to Assistant Administrator Alexander Solorio.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2