198603286-2-23-2024-28-AS-DSIS-D32R4R-20240304114156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 02/23/2024
Date Signed: 02/23/2024 01:22:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
02/20/2024 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240220165855

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: 78	DATE:	02/23/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Staff handled a resident in a rough manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit regarding the above allegation. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit.

The investigation consisted of the following:

LPA obtained copies of Staff and Resident Rosters, reviewed surveillance footage of the alleged incident, obtained Police Report Number and card of Officer, Copies of SOC341 and Incident Report were given to LPA, and interviews with 4 Staff and 7 Residents were conducted.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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-20240220165855

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 02/23/2024

NARRATIVE

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The investigation revealed the following:

Allegation: Staff handled a resident in a rough manner.

It is alleged that Staff #1 (S1) grabbed and dug their nails into Resident #1 (R1) wrists. LPA reviewed the surveillance footage of alleged incident and what was observed was R1 in their wheelchair moving towards kitchen with a plate of food on their lap and can be seen speaking to someone ahead of them, as they approached the kitchen you can see S1 (only hands and arms were visible) attempting to take the plate of food from R1’s lap, but R1 tightens their grip on the plate, S1 releases the plate and walks away, R1 continues to move backwards in their wheelchair with plate of food on lap appearing to be yelling and waving a finger in the direction of where S1 was, nothing further was observed. LPA interviewed S1 and Staffs story matched what was observed in the surveillance footage and S1 stated they have been working in their field for many years and have never spoken inappropriately nor inappropriately touched any residents. LPA interviewed a total of 4 Staff and 4 out of 4 Staff stated they have never spoken inappropriately, yelled, touched, or handle any resident in a rough manner, and have never seen another staff do these things either. LPA interviewed 7 Residents during visit and 7 out of 7 Residents stated that they have never been mistreated, yelled at, or handled roughly by any staff at facility. R2 stated that they were present during the time of the alleged incident and did not see S1 touch R1, that S1 attempted to grab the plate of food from R1’s lap, R1 refused, and S1 walked away.

Based on statements and interviews conducted with Staff and Residents, and LPA’s observation, there was not enough supportive evidence to concur with the reported allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to Alex Solorio.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

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