198603286-9-15-2025-28-AS-LHIS-DNXQJB-20251201111225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 09/15/2025
Date Signed: 09/15/2025 02:35:39 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
08/20/2025 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250820145116

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: 56	DATE:	09/15/2025
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Bryanna Luke - Administrator		TIME COMPLETED:	12:43 PM

ALLEGATION(S):

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Resident sustained unexplained injury while in care due to staff neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Penai conducted a subsequent complaint visit regarding the above allegation. LPA discussed the purpose of the visit with Administrator, Bryanna Luke.

The investigation consisted of the following: On 08/21/2025, LPA conducted a tour of facility and common areas and obtained a copy of the Staff and Resident rosters, facility sketch, pertinent files for Resident #1 (R1) - Resident #2 (R2), Unusual Injury/Incident Reports (SIR) (May - Aug 2025). Administrator provided a copy of the completed SOC341 (dated 08/21/2025) and Pasadena Police Dept report #2025-65144. LPA also requested House rules, Home Health Notes and Nurse's Notes for R1-R2.

During today's visit, LPA obtained a copy of the Staff and Resident rosters, Unusual Injury/Incident Reports (July-Aug 2025) for R1 and reviewed pertinent files for R1 including nurses notes and hospital discharge records. LPA also interviewed Staff #1 (S1) - Staff #4 (S4) and Resident #2 (R2) - Resident #10 (R10). R1 is currently in the hospital, therefore not interviewed. ******CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

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-20250820145116

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: 09/15/2025

NARRATIVE

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The investigation revealed the following:

Allegation: “Resident sustained unexplained injury while in care due to staff neglect.” It is alleged that R1 has dementia and frequently falls several times a day, including an unwitnessed fall on August 11, 2025, resulting in left hand injury. (4) out of (4) staff interviewed stated that caregivers conduct routine checks every 2 hours or more often if needed. However, R1 requires a higher level of care or 1:1 supervision because of their medical condition and R1 does not have a one-on-one caregiver. Staff interviewed stated that when R1 had an unwitnessed fall on 08/11/2025, a med tech was called by a caregiver who immediately assessed R1, provided first aid and sent R1 to the hospital, where R1 stayed until August 15, 2025, and received stitches for the injury. Additionally, staff interviewed stated they also provided fall mats to R1 and increased their physical therapy sessions to help prevent R1 from falling and sustaining injuries. All (9) residents interviewed denied the allegation, while (7) of the (9) were unaware of the incident. (3) out of (9) interviewed residents experienced a fall and stated the staff conducted body checks, assessed and attended to them. Residents interviewed also stated that staff conduct routine checks daily. Therefore, there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the 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 conducted and a copy of this report was provided to Bryanna Luke, Administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

LIC9099 (FAS) - (06/04)

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