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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 12/21/2023
Date Signed: 12/21/2023 01:49:48 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
12/15/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231215162057
FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 75DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Madison AcevesTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff did not provide resident with medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)Wong conducted an initial 10 days complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Receptionist Scarlett Munoz who allowed entry into the facility and was later met by Admission Director Madison Aceves who assisted with the visit.

The investigation consisted of the following: LPA interviewed seven (7) residents (R2-R8), three (3) staff in the facility and Resident#1 (R1) sister in the facility and assistant administrator via telephone and obtained documents including: staff and residents rosters, R1's face sheet, physician report, needs and service plan, care plan, medication list and also reviewed R1-R7 medication in the facility.

(See LIC 9099C for continuation)

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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-20231215162057
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: 12/21/2023
NARRATIVE
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The investigation revealed of the following: Allegation "Staff did not provide resident with medications as prescribed. " LPA interviewed seven residents, seven out of seven denied the allegation and reported staff take good care of their medication and staff administrated their medication daily. LPA interviewed staff and stated R1's sister dropped off the medication after R1 was discharged from the hospital but without any doctor's order and it's an injected medication which the facility cannot administer (Fulphia). The staff told R1's sister that they cannot administer as they are not a medical facility. LPA also inspected seven (7) residents' medication and all the medication are centrally stored and all resident medication are following with the doctor's order and seemed accurate and updated.

Based on the interviews conducted, observation and documents reviewed, 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 the report was provided
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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
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
12/15/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231215162057

FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 75DATE:
12/21/2023
UNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Madison AcevesTIME COMPLETED:
02:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure resident had oxygen.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA)Wong conducted an initial10 days complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Receptionist Scarlett Munoz who allowed entry into the facility and was later met by Admission Director Madison Aceves who assisted with the visit.

The investigation consisted of the following: LPA interviewed seven (7) residents (R2-R8), three (3) staff and Resident#1 (R1) sister in the facility and assistant administrator via telephone and obtained documents including: staff and residents rosters, R1's face sheet, physician report, needs and service plan, care plan, medication list and also reviewed R1-R8 medication in the facility.

(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
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-20231215162057
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: 12/21/2023
NARRATIVE
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The investigation revealed of the following: Allegation "Staff did not ensure resident had oxygen." It's alleged that R1's oxygen tanks were not filled and R1 had no oxygen. LPA interviewed staff and stated R1 was discharged from the hospital along with the oxygen tank. Staff reported R1 has been in and out from the hospital recently. LPA asked staff if R1's oxygen tank were empty while R1 was sent out to the hospital and staff stated they do not know anything about it. According to the hospital staff, a witness was observed R1's oxygen tank were not filled and R1 had no oxygen.

Based on the observation and interviews conducted with staff, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit Interview conducted and a copy of the report and appeal right was provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20231215162057
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87618(b)(3)(H)
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87618 Oxygen Administration-Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (H) Equipment shall be operable.
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Licensee agreed to review Title 22 Regulations, 87618(b)(5) and submit a written plan detailing how administrator would ensure staff understand how to operate the oxygen equipment. Licensee would provide proper training to staff how to operate the oxygen machine. POC due on 12/22/23
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The requirement was not met as evidenced by a witness observed R1 oxygen tanks were not filled and R1 had oxygen which posed a immediate risk to residents in care.
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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: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5