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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 01/12/2024
Date Signed: 01/12/2024 03:29:15 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
12/14/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231214121543
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: 75DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Alexander Solorio - Assistant AdministratorTIME COMPLETED:
03:01 PM
ALLEGATION(S):
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9
Facility staff are not properly addressing pest infestation in facility.
Facility staff are not addressing tripping hazards on the facility floor.
Facility staff are not providing residents with furniture that is in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 12/21/2023, LPA Mora obtained copies of staff & resident rosters, interviewed Admission Director, Staff 1 - Staff 2 (S1 - S2) and Resident 1 - Resident 4 (R1 - R4), and toured the facility kitchen, dining room and 8 rooms. During today's visit, LPA obtained copies of staff & resident rosters, interviewed Assistant Administrator, Staff 3 - Staff 4 (S3 - S4), Resident 5 - Resident 8 (R5 - R8) and Pest Control Company, obtained copies of monthly pest control invoices dating back to October 2023, housekeeping schedule, reviewed food delivery receipts for the entire month of December 2023, and conducted a tour of the kitchen, dining room, and 8 rooms.

(Continued to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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-20231214121543
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: 01/12/2024
NARRATIVE
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The investigation revealed the following: regarding the allegation "facility staff are not properly addressing pest infestation in facility", it is alleged that on 12/13/2023 cockroaches were observed in the kitchen of the facility and a dried maggot on the soda machine dispenser spout. Assistant Administrator and 3 staff denied the allegation and stated that pest control comes on a monthly basis. The complainant stated that they asked a staff to dispose of the cockroaches that they found which were alive. LPA interviewed this staff and confirmed the complainant's statement to be true. LPA observed monthly pest control invoices dating back to October 2023. However, LPA contacted the pest control company and stated that in the last 3 months they have only service the outside of the building. They only do the inside of the facility if it requested by the facility. Per their records, there was a request made to conduct pest control services inside the facility and it was scheduled for 12/18/2023 at night, but they were unable to conduct this service because they were not able to get inside the kitchen. Pictures and videos of alive cockroaches in the kitchen were submitted to the Community Care Licensing Division (CCLD) along with this complaint. A picture of the soda machine dispenser spout showing what appears to be a dried maggot was also submitted. On 12/21/2023, LPA observed dead cockroaches in the kitchen and could not identified whether the soda machine dispenser spout had a dried maggot or dried syrup. However, the soda machine dispenser spout did appear to be unsanitary and this will be cited on a separate report. Four of the residents interviewed stated that they have seen cockroaches in either their rooms or hallway.

Regarding the allegation "facility staff are not addressing tripping hazards on the facility floor", it is alleged that there are pieces of the flooring that are lifted in multiple locations around the facility. On 12/21/2023, LPA observed floor tile lifting in the dining room and loose/damaged floor tile in room #23. During today's visit, the Assistant Administrator stated that the flooring tile in the dining room has been fixed and LPA confirmed. The floor tile in room #23 still needs repair.

Regarding the allegation "facility staff are not providing residents with furniture that is in good repair", it is alleged that in room #23 and #46 both of the residents' dressers were broken into pieces and in room #40 the dresser and table were broken and not able to be used properly. On 12/21/2023, LPA observed that room #40 one of the dresser's drawer was broken into pieces and the table was in good condition. In room #46 one of the drawers of the dresser is loose and it is not sliding in or out properly. LPA did not observed any damage to the furniture in room #23 and confirmed with the resident in that room.

Based on observation, record review and interviews conducted, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.

Exit interview held and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20231214121543
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: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2024
Section Cited
CCR
87555(b)(27)
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General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
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Facility is to ensure that Title 22 Section 87555 regulations are met at all times. Additionally, facility will submit a plan on how they will address the cockroach issue by 01/13/2024.
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. There is sufficient evidence to support that the facility has a cockroach issue.
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Type B
01/19/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement is not met as evidenced by:
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Facility is to ensure that Title 22 Section 87303 regulations are met at all times. Additionally, facility will repair the damaged floor tile in the dining room and room #23 and repair or replace the furniture in room #40 and #46, and will submit proof by 01/19/2024.
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Based on observation and interviews, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. LPA observed floor tile lifting in the dining room and and damaged floor tile in room #23, and damaged furniture in room #40 and #46.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
12/14/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231214121543

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: 75DATE:
01/12/2024
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Alexander Solorio - Assistant AdministratorTIME COMPLETED:
03:01 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff does not maintain an adequate food supply for residents.
Facility staff are not maintaining the washing machines in good repair.
Facility staff are not providing residents with assistance in cleaning their rooms.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 12/21/2023, LPA Mora obtained copies of staff & resident rosters, interviewed Admission Director, Staff 1 - Staff 2 (S1 - S2) and Resident 1 - Resident 4 (R1 - R4), and toured the facility kitchen, dining room and 8 rooms. During today's visit, LPA obtained copies of staff & resident rosters, interviewed Assistant Administrator, Staff 3 - Staff 4 (S3 - S4), Resident 5 - Resident 8 (R5 - R8) and Pest Control Company, obtained copies of monthly pest control invoices dating back to October 2023, housekeeping schedule, reviewed food delivery receipts for the entire month of December 2023, and conducted a tour of the kitchen, dining room, and 8 rooms.

(Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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-20231214121543
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: 01/12/2024
NARRATIVE
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The investigation revealed the following: regarding the allegation "facility staff does not maintain an adequate food supply for residents.", it is alleged that lack of fruits and vegetables for the number of residents in care. Assistant Administrator and staff denied the allegation. Assistant Administrator stated that they received food delivery on Mondays and Thursdays, and that they always have enough vegetable and fruits for all residents. Residents interviewed could not corroborate the allegation. On 12/21/2023, LPA observed sufficient vegetables and fruits in the kitchen freezer. During today's visit, LPA reviewed the facility's food delivery receipts for the whole month of December 2023 and observed that sufficient vegetables and fruits are being delivered every Monday and Thursday.

Regarding the allegation "facility staff are not maintaining the washing machines in good repair", it is alleged that one of the two washers are broken and not able to be fixed. Assistant Administrator and staff denied the allegation. Assistant Administrator stated that both their washers have been working in the recent months. There was one broken washing machine that was immediately replaced back in June 2023 and it was placed in the storage room and on 12/11/2023 it was taken to the back of the facility along with other junk for the trash company to come pick it up. Residents interviewed could not corroborate the allegation and none expressed any issues with laundry needs. On 12/21/2023, LPA observed both washing machines in the laundry room to be properly operating.

Regarding the allegation "facility staff are not providing residents with assistance in cleaning their rooms", it is alleged that food crumbs were observed on the ground of residents bedrooms. Assistant Administrator and staff denied the allegation. Assistant Administrator stated that deep cleaning is provided once a week and minor cleaning is provided on a daily basis or as needed. Residents interviewed could not corroborate the allegation and none expressed any issues with housekeeping needs. On 12/21/2023, LPA observed housekeeping going around cleaning the residents rooms. During today's visit, LPA reviewed the housekeeping schedule which shows the days that common rooms and residents bedrooms are deep cleaned. The housekeeping schedule also states at the bottom for staff to check all rooms daily to see if any room needs additional cleaning.

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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5