198603286-1-4-2024-28-AS-LHIS-CZYKP2-20240130070359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 01/04/2024
Date Signed: 01/04/2024 04:32:35 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
06/30/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230630094920

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:	01/04/2024
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Assistant Administrator-Alexander Solorio		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff handle residents roughly during diaper changes.
Residents are afraid of retaliation from staff if they disclose concerns to the Ombudsman and Licensing.

INVESTIGATION FINDINGS:

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

On 07/06/2023, the investigation consisted of the following: LPA Calderon collected staff and resident roster and resident #1 (R1) and resident #4 (R4) recent service tracker log. LPA Calderon interviewed Assistant Administrator Alex and Staff #1 (S1). LPA interviewed Residents #1-#7 all whom were incontinent care residents. LPA observed and tested Signal system buttons (pendants) in room 4, room 6, room 8, room 14 and room 40. During visit LPA tested signal system and staff assisted in a timely manner, staff responded to residents between 2 minutes- 17 minutes when pendant was tested.

On today's visit 1/4/23, LPA's investigation consisted of interview with Staff #2-Staff #4 (S1-S4). Toured facility for required postage of Ombudsman poster and Licensing poster

Continuation on 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: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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-20230630094920

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: 01/04/2024

NARRATIVE

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Based on Allegation: Staff handle residents roughly during diaper changes. Investigation revealed:
Assistant Administrator and S1-S4 informed LPA that they haven't witnessed or observed any staff handling residents roughly when having their adult brief's changed. (5) out of (5) staff informed LPA during interviews that they change every incontinent residents in a proper way that is not rough and deny the above allegation. (5) out of (7) residents informed LPA staff haven't treated them rough when getting their adult brief's changed.

Based on Allegation: Residents are afraid of retaliation from staff if they disclose concerns to the Ombudsman (LTCO) and Licensing (CCLD). Interviews with (7) out (7) residents interviewed on 7/6/23 LPA was informed that resident deny the above allegation and they are not afraid of staff retaliating residents if disclosing information. R1 informed LPA they are not afraid of retaliation by staff but concern they staff ask what was disclosed to CCLD and LTCO. LPA observed CCLD and LTCO posters with information to contact agencies per rights of the residents/ staff and visitors located in the hallway.

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: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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
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
06/30/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230630094920

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:	01/04/2024
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Assistant Administrator-Alexander Solorio		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Night staff do not respond to assist residents with care

INVESTIGATION FINDINGS:

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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: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20230630094920

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: 01/04/2024

NARRATIVE

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Based on allegation: Night staff do not respond to assist residents with care. (4) out of (7) residents interviews with LPA on 7/6/23 revealed caregivers did not attend to residents during the night. Although residents were not able to inform LPA with a time frame on wait time residents informed LPA they would wait for a long time or the night staff were not doing rounds to check on them. (3) out of (5) staff during interviews informed LPA being aware of residents informing staff that night shift staff were not efficiently responding attending to residents at night. S3 and S4 informed LPA R1 calls staff frequently around 3-5 minutes asking for assistance and although R1 may need to wait at times because staff are doing their duties and caregiving are attending to all residents needs, R1 does receive assistance.LPA reviewed resident(s) in-service log sheet for R1, R2, R4 R5 logs showed no indication of nocturnal shift logging in-service for residents listed between months of June-July 2023. Assisted Administrator and S1 stated caregivers duties are to check on residents every 2 hours during rounds and as needed.

Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations per Title 22, 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 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: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230630094920

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: 01/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/26/2024 Section Cited CCR 87415(a)	1 2 3 4 5 6 7	Night Supervision(a)The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with....planned emergency procedures, shall be trained in first aid..., Incidental Medical and Dental Care Services and shall be available as indicated below to assist in caring for residents in the event of an emergency.	1 2 3 4 5 6 7	Administrator will have a training to refresh staff on care and supervision with night shift staff and review Regulations : 87415 Night Supervision, Health and Safety Reg on Basic Services Requirement 1569.312 and Care and Supervision 1569.2. and go over in-service log and how to properly check on resident's through the night especially incontinent residents. Admin. will provide LPA with in-service sign in sheet and materials used during training.
	8 9 10 11 12 13 14	The requirement was not met as evidenced by: LPA reviewed R1, R2, R4 R5 in-service alongside with Staff #1(S1) and there were no identifier's showing nocturnal shift provided care and supervision to resident(s). Interviews with (3) out of (5) staff stated residents were being aware of issues with noc shift caring for residents. Interviews with residents (4) of (5) informed LPA night shift staff were not assisting/ responding to residents to provide care and supervision .	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: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC9099 (FAS) - (06/04)

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