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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:43:13 PM

Substantiated


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
02/07/2023 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20230207163621
FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 76DATE:
01/16/2024
UNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Maria Razo - Resident Care Director TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident eloped from facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Maria Razon and explained the reason for the visit.

The investigation consisted of the following: On 2/14/23 LPA Flores conducted an initial visit at the facility and requested a copy of resident/staff rosters, physician's report, identification and emergency sheet, incident reports for resident #1 and #2(R1-R2), discharge documents for R1 for the months of July and August for 2022 for R1 and R2 . LPA Flores interviewed resident #1(R1) and staff #1(S1),#2(S2). On 8/23/23 LPA Flores subpoena Medical Records from Huntington Hospital for R1 and faxed Pasadena Police Department Record Division. On 11/1/23 LPA followed up on subpoena. On 11/16/23 LPA followed up on subpoena documents in person/email, and faxed Pasadena Police Department Record Division. On 11/17/23 LPA Flores received subpoena documents for R1. . On 1/16/24 LPA Flores conducted interviews with 4 additional residents and 3 additional staff. (CONTINUED ON LIC (9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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 5
Control Number 28-AS-20230207163621
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: 01/16/2024
NARRATIVE
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The investigation consisted of the following: Regarding allegation: Resident eloped from facility. It is alleged R1 was lost during the summer of 2022 and picked up by police. Interviews conducted revealed the following: Administrator stated R1 is not a wander and does not leave the facility unattended. Interview with staff revealed R1 has not left the facility unattended, due to R1’s sight tends to wander inside the facility. However, with redirection R1 finds way back to where R1 needs to go. Interview with R1 revealed, R1 does not leave the facility and does not feel comfortable leaving due to R1’s sight not being great and not knowing the area. Interviews with other residents revealed those that are able to leave the facility unattended do. Upon leaving the facility they notify the staff and when they return they let staff know they are back. Documents reviewed revealed: Incident Report dated 7/4/22 notes R1 went out with another resident on 7/2/22 and did not return to the facility, due to a disagreement between the two residents. The following day R1 continue to be out of the facility. Facility staff proceeded to call hospitals and Pasadena Police Department. It was found R1 was taken to the hospital due to sustaining a fall. R1’s responsible party was notified, who requested R1 not go out due to R1 not being familiar with the area. Physician’s report dated 5/6/22 notes R1 cannot leave the facility unassisted due to visual impairment. Although R1 left the facility with another resident. R1 was not assisted by a staff or responsible party. Therefore, allegation of resident eloping is substantiated.

Based on LPAs interviews and record review which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 being cited on the attached LIC 9099D.


***An immediate Civil Penalty of $500.00 is being issued today, due to absence of supervision. Refer to LIC 421IM***

Exit interview was conducted with Maria Razo and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230207163621
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...care facilities ... shall... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are ...to meet their needs.
This requirement is not met as evidence by:
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Administrator will certify in writing that will ensure that residents do not leave unassisted unless assisted by a staff or responsible party and will provide in-service training to staff to inform staff of which residents are able to leave the facility unassited and which are not and will submit a copy of in-service to
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Based on documents review licensee did not ensure R1 did not leave the facility unassisted which resulted on a fall which poses an immediate risk to the health,safety, or personal rights of the person in care. *Immediate civil penalities assess for $500.00*
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the department by POC due date 1/17/23.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/07/2023 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20230207163621

FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 67DATE:
01/16/2024
UNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Maria Razo - Resident Care Director TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
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9
Facility abandoned resident at hospital.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Maria Razon and explained the reason for the visit.

The investigation consisted of the following: On 2/14/23 LPA Flores conducted an initial visit at the facility and requested a copy of resident/staff rosters, physician's report, identification and emergency sheet, incident reports for resident #1 and #2(R1-R2), discharge documents for R1 for the months of July and August for 2022 for R1 and R2 . LPA Flores interviewed resident #1(R1) and staff #1(S1),#2(S2). On 8/23/23 LPA Flores subpoena Medical Records from Huntington Hospital for R1 and faxed Pasadena Police Department Record Division. On 11/1/23 LPA followed up on subpoena. On 11/16/23 LPA followed up on subpoena documents in person/email, and faxed Pasadena Police Department Record Division. On 11/17/23 LPA Flores received subpoena documents for R1. . On 1/16/24 LPA Flores conducted interviews with 4 additional residents and 3 additional staff. (CONTINUED ON LIC (9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230207163621
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: 01/16/2024
NARRATIVE
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The investigation revealed the following: Regarding allegations: Facility abandoned resident at hospital. It is alleged hospital has attempted several times to call facility and was not able to communicate for discharge. During file review conducted on 2/14/23 there were only 2 residents that went out to the hospital during the time of the allegations and per the allegations only R1 meet the criteria for allegations. Interviews conducted revealed: Administrator maintains a group chat to communicate with care staff regarding sending or discharge of residents to and from hospital. Phone lines have been working. Interviews with residents revealed to not have heard of residents having difficulties returning to the facility upon discharge. Interviews with staff revealed staff are aware when residents go and return form the hospital and keep a chat that notifies each other when a resident is being discharge back to the facility. As well as reception staff respond and are notified by the hospital when a resident is being discharge back to the facility. Documents reviewed for R1, reveal R1 has gone out to the hospital twice, on 1/17/23 and on 2/3/23 for the same health complaint. Huntington Hospital Medical Records subpoena for R1’s visit on 2/3/23 revealed no notes that determined facility was not responding hospital for discharge noted. R1 was discharge back to the facility on 2/8/23.

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

Exit interview was conducted with Maria Razo and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5