198603286-1-9-2024-28-AS-TVAO-CZXRZC-20240129122736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:33:04 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
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: 74	DATE:	01/09/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Alexander Solorio / Assistant Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff do not maintain clean showers for residents use.
Staff do not provide resident with basic laundry service.
Staff do not provide residents with housekeeping services.
Facility does not ensure residents have hot water for showers.
Facility staff does not make menus available for review by resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 2/14/23 LPA Calderon obtained a copy of the Staff/Resident rosters and Resident #1's (R1) Admission Agreement. 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 Assistant Administrator 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 #6 (S6) and interviewed Residents #2-6 (R2-R6).

(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: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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 3

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: 01/09/2024

NARRATIVE

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On today's visit 1/9/24, LPA toured common shower rooms, measured hot water in shower rooms, observed food menu, and attempt to interview staff #6 (S6) and attempt interview with R1, LPA received and reviewed housekeeping refusal slips. LPA reviewed documentation's provided on 2/14/23.

Based on allegation: Staff do not maintain clean showers for residents use. The investigation revealed the following: LPA interview with staff, 6 out of 6 staff informed LPA they deny the above allegation and shower rooms are kept clean for residents. 3 out of 6 staff members informed LPA that cleaning services are done to maintain cleanliness. Interviews with residents on 2/14/23, 3 out of 5 resident's informed LPA that shower's are maintained clean and resident's denied the above allegation. Resident #2 and resident #5 do not use facility showers and cannot collaborate to the above allegation. LPA Calderon observed on visit dates 2/14/23 and 1/9/24 common shower rooms maintained clean and housekeeping staff cleaning shower rooms. LPA reviewed shower / bedding schedule for residents in care, residents per schedule review receive 2 shower days a week and that R1 was on the schedule twice, for assigned shower dates.

Based on allegation: Staff do not provide resident with basic laundry service. The investigation revealed the following: Based on interviews conducted with staff, 5 out of 6 staff members informed LPA that residents receive laundry services and it is based on the laundry schedule, each residents have a schedule date for laundry services. Interviews with residents on 2/14/23 revealed that 5 out of 5 residents informed LPA that the facility provides laundry services to the resident's in care. LPA reviewed laundry services schedule and reviewed R1 scheduled for laundry services once a week, per laundry schedule residents have 1 day of laundry services. LPA during 2/14/23 visit to the facility, observed working laundry machines.

Based on allegation: Staff do not provide residents with housekeeping services. The investigation revealed the following: Interview with staff, 5 out of 6 informed LPA that housekeeping staff provide housekeeping services for residents. Interviews with residents on 2/14/23 revealed that 5 out of 5 resident's informed LPA that residents are providing housekeeping services and denied the above allegation. LPA during 2/14/23 visit to the facility, LPA toured random rooms: Room 1, Room 33, Room 39, Room 40, and Room 46; LPA observed clean rooms. On visit date 1/9/24 LPA observed two house keepers on shift cleaning resident's rooms and bathrooms. LPA reviewed R1's refusal of housekeeping services slips, R1 refused housekeeping on February 18 & 24, 2023, March 11, 2023 and April 12 ,17 & 15,2023, slips show staff attempting to provide services for R1. .
(CONTINUATION 9099-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 01/09/2024

NARRATIVE

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Based on Allegation: Facility does not ensure residents have hot water for showers. The investigation revealed the following: 6 out of 6 staff during interview denied the above allegation and informed LPA there is hot water at the facility for residents to shower with. Staff #2- Staff #4 (S2,S3 & S4) informed LPA that hot water in certain common shower rooms takes time to heat up but shower's do deliver hot water. Interviews with residents 4 out of 5 resident's informed LPA that facility has hot waters for showers. R5 cannot collaborate to the above allegation. LPA on visit dates 2/14/23 and 1/9/24 tested hot water in common shower rooms. On 2/14/23 and 1/9/24, hot water was measured and tested and measured between the required Title 22 regulation. LPA tested water and LPA observed hot water taking some time for water to get hot between the required Title 22 measurements.

Based on Allegation: Facility staff does not make menus available for review by resident. During the Investigation the following was revealed: During investigation 5 out of 6 staff stated the food menu is readily available for residents to review. S3 was unable to collaborate as their job duties does not pertain to working in the kitchen nor dining room. Interviews with residents on 2/14/23 LPA was informed by 6 out of 6 residents either couldn't collaborate with the allegation above due to not being aware, cannot see, not aware and/ or doesn't care. LPA observed on 2/14/23 and 1/9/24 food menu posted located in kitchen and dining room for resident's review.

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC9099 (FAS) - (06/04)

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