198603286-1-5-2024-28-AS-DSIS-CZXRCT-20240129115450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 01/05/2024
Date Signed: 01/05/2024 03:13:51 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-20231002104939

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:	DATE:	01/05/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Assistant Administrator-Alexander Solorio		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff not providing adequate supervision resulting in resident-on-resident altercation.

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 Assistant Administrator Alexander Solorio, Staff 1-4 (S1-S4) and Residents 1-7 (R1-R7). R1 was not interviewed as resident was not at the facility at the time of the visit. LPA collected copies of Staff and Resident Rosters, Resident #1 and Resident #2 (R1 and R7) face sheet, physician's report and appraisal / needs and service plan. LPA also collected a copy of Unusual Incident/ Injury Report dated 09/29/23, SOC 341 self reporting dated 9/29/23, and Skin Integrity Report for R1 dated 10/6/23.

On today's visit, 1/5/24, LPA Calderon along side with LPA Tena Herrera conducted interview with R1. LPA conducted interview with R3. LPA reviewed records provided on 10/10/23 for residents R1 and R7. (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-20231002104939

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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Allegation regarding: Staff not providing adequate supervision resulting in resident-on-resident altercation. The investigation revealed the following: S2 during LPA interview conducted informed LPA S2 was passing by R1 and R7 room when hearing an argument between roommates and S2 approached room to see what was occurring. (5) out of (5) interviews conducted informed LPA staff do resident room checks throughout the day and intervene between residents when altercations occur. During interview with R1 conducted on 1/5/23 R1 stated facility did the best they can and roommates were separated into different rooms. R7 denied altercation occurring between self and R1. (5) out of )7) resident interviews informed LPA that facility staff provide adequate supervision and assist residents when altercations arise between residents. It was reported with interview by Hospital staff that are R1 stated to them during hospital visit that staff member walked into residents room were altercation took place and broke up altercation. LPA Calderon reviewed Special Incident Report (SIR) dated 9/29/23 per report: R1 and R7 were involved in an verbal altercation in the AM and S2 observed altercation and S2 as approaching situation observed R2 hitting R1. Action conducted by S2 was to provide first aid to R1 and R1 was taken to the hospital and once R1 returned to the facility after hospital discharge R1 was offered to move rooms. Record review on SOC 341 provided to LPA completed by Assistant Administrator was reviewed and submitted to licensing in a timely manner with SIR, SOC states R1 and R7 were roommates and due to altercation resident's became ex-roommates. LPA reviewed Skin Integrity Report regarding R1 and states staff S2 assisted with care due to injury sustained during altercation.

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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