198603286-1-5-2024-28-AS-DSIS-CZY26P-20240129160729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 01/05/2024
Date Signed: 01/05/2024 01:31:07 PM

Unsubstantiated

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
10/02/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231002130434

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:	08:30 AM
MET WITH:	Assistant Administrator- Alexander Solorio		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not ensure that resident's toileting needs were met while in care.
Staff did not ensure that resident's hygiene needs were met while in care.
Staff do not provide assistance to resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced subsequent complaint investigation visit at the facility regarding the above allegations. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit.

The investigation consisted of the following: On 10/10/23, LPA Calderon conducted interviews with Staff #1-4 (S1-S4) and Residents #1-7 (R1-R7). LPA collected copies of Staff and Resident Rosters. LPA collected and reviewed R1's Face Sheet, Physician Report and R1's Appraisal/ Needs and Service Plan and Incident Reports for incidents relevant to the investigation. LPA via telephone interviewed Case Manager for R1 from DHS- Exodus Recovery.

On today's visit date 01/05/24, LPA collected and reviewed Special Incident Reports (SIR) for incidents relevant to the investigation, R1 meeting notes with R1's care team and conducted interview with Assistant Administrator. (Continuation 9099-C)

Unsubstantiated

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: 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-20231002130434

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: 01/05/2024

NARRATIVE

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Regarding allegation: Staff did not ensure that resident's toileting needs were met while in care. (5) out of (5) staff interviews conducted LPA was informed all residents who require toileting assistance get assistance by staff. (5) out of (5) staff informed LPA their are no residents who are left covered in feces and urine. Assistant Administrator and S4 informed LPA R1 would call the police if they did not get assistance right away upon their request. Per record review on staff notes with DHS meeting for R1 states facility stating concern for R1 due to refusing assistance from staff at times. Per Pasadena Police Department Officer Moreno observed R1 not covered in feces and urine and being assisted by facility staff during time of visit. LPA during interview with R1 was observed to not covered in feces and urine.

Regarding allegation: Staff did not ensure that resident's hygiene needs were met while in care. (5) out of (5) interviews with staff, LPA was informed denying the above allegation and that residents are provided assistance with hygiene needs like shower, adult brief and clothing change, laundry services and linen change. During record review special incident report for R1 dated 9/30/23, 10/20&26/23, and 11/18/23 states staff attempt to assist R1 and R1 would refuses assistance from staff personnel's. Per record review on staff notes with DHS meeting for R1 states facility stating concern for R1 refusing assistance from staff at times. LPA observed R1 during interview to be groomed and appears to have hygiene needs met.

Regarding allegation: Staff do not provide assistance to resident in a timely manner. LPA interview with (5) out of (5) staff stated resident's get assisted in a timely manner and denied the above allegation. (3) out (5) staff informed LPA residents get check on when calling the signal system or asking for assistance within 5-15 min time frame and if staff are in the middle of job duties helping other residents, staff communicate with resident's letting them know they will be attended to shortly or front office staff assist residents when caregivers are busy attending to others. (4) out (5) staff informed LPA that R1 would not want to wait at all when they requested assistance and at times would refuse care needs. (5) out of (7) residents in care during interviews conducted on 10/10/23 residents informed LPA that they personally are assisted with their activities of daily living in a timely manner and denied the above allegation. Record review on special incident report regarding R1 states staff multiple times attempt to assist R1 and due to R1's behaviors and refusing care R1 calls 911 reports being neglected even when staff attempt to assist resident. During record review special incident report for R1 dated 9/30/23, 10/20&26/23, and 11/18/23 states staff attempt to assist R1 and R1 would refuses assistance from staff personnel's.Per record review on staff notes with DHS meeting for R1 states facility stating concern for R1 refusing assistance from staff at times.Police documentation with Pasadena Police Department Officer Moreno stated neglect and abuse allegation regarding R1 was unfounded.

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 allegations are UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
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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