198603286-2-14-2023-28-AS-TVAO-CZXRZD-20240129122736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 02/14/2023
Date Signed: 02/14/2023 03:26:41 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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 Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230207105455

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: 69	DATE:	02/14/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Assistant Administrator - Alexander Solorio		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility does not ensure that food of good quality is being served to residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander "Alex" Solorio (Assistant Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained a copy of the Staff/Resident rosters, Resident #1's (R1) Admission Agreement, Alex will send LPA Calderon an email on R1 shower and housekeeping refusal. LPA obtained facility laundry schedule for residents, residents shower schedule, food menu, food alternative slips, Staff #1, Staff #2 and Staff #6 (S1, S2 and S6) food handler training certifications. LPA Calderon alongside with Alex toured kitchen/cafeteria, three resident showers, residents rooms: Room 1,Room 33, Room 39,Room 40, and Room 46 and laundry room. LPA Interviewed Staff #1- #5 (S1-S5), attempt interview Staff #7 (S7) and interviewed Residents #2-6 (R2-R6).

Continue to LIC9099C....

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

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 4

Control Number 28-AS-20230207105455

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 02/14/2023

NARRATIVE

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Allegation: Facility does not ensure that food of good quality is being served to residents in care. LPA Calderon along side with Assistant Administrator Alexander Solorio and S2 observed old rotten, molded / fungus and discoloration vegetables and fruits in storage room, being in unsanitary condition for residents to consume. Based on LPA Calderon interviews conducted with R2, R3, R5 the statements obtained were consistent and corroborated with the allegation that facility is not ensuring the food quality residents are being served.

Based on LPA’s observations and interviews which were conducted: the preponderance of evidence standard has been met, therefore the above allegation are found to be Substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 8, Article 6 ), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator Alexander Solorio along with the Appeals Rights.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20230207105455

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 02/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/15/2023 Section Cited CCR 87555(b)(8)	1 2 3 4 5 6 7	87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. The requirement is not met as evidenced by:	1 2 3 4 5 6 7	Assistant Administrator immediately notified kitchen staff to remove unsanitary food items and develop a plan to maintain good quality, fresh food for residents in care. Administrator will provide in-service food training on food handling will provide LPA with in servicie training. Will obtain Quality food check log. Assistant Administrator will submit proof of correction to CCL by the POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted: LPA observed food quality for perishable foods (vegetables and fruits) containing bacteria, fungus and mold. Food in unsanitary conditions for residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

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