198603286-7-7-2025-28-AS-DSIS-DJLM2V-20250715091408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/07/2025
Date Signed: 07/07/2025 04:25:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
07/02/2025 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250702150727

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: 54	DATE:	07/07/2025
		UNANNOUNCED	TIME BEGAN:	11:06 AM
MET WITH:	Bryanna Luke, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff do not ensure the facility is properly maintained.
Staff do not ensure facility remains free of bad odors.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted an Initial 10-Day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator, Bryanna Luke.

The investigation consisted of the following: LPA requested the Staff & Resident Roster. LPA also interviewed Resident #1 (R1) to Resident #11 (R11), the Administrator, and Staff #1 (S1) to Staff #4 (S4), and the maintenance handyman.

The investigation revealed the following: in regard to the allegation " Staff do not ensure the facility is properly maintained.", it is alleged that toilet in Rm#49 has been clogged since 6/27/25, and staff did not do anything to address it. There is a sign on by the bathroom door in Rm#49 that instructs the resident to use the bathroom next to the medication room. It is alleged that the bathroom next to the medication room is locked. One (1) out of eleven (11) residents corroborated with the allegation. Ten (10) out of eleven (11) residents interviewed denied the allegation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

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 3

Control Number 28-AS-20250702150727

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 07/07/2025

NARRATIVE

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However, three (3) out of eleven (11) residents interviewed stated that it took a few days to unclog the toilet and that the alternate bathroom they could use while their toilet was clogged was too far from their room. The administrator and all four (4) staff interviewed denied the allegation. The administrator stated that when the clogged toilet was reported to the receptionist on 06/28/2025, the on-duty care staff attempted to unclog the toilet with the toilet on that day but was unable to unclog it. Based on interview, the maintenance facility handyman stated that the toilet was fixed and unclogged on 07/01/2025 and the cause of the clogged toilet was due to excessive paper towels put in the toilet drain. One (1) out of four (4) staff interviewed also stated that the staff have informed the residents to not to put too many paper towels in the toilet. Based on observation, the LPA Konishi checked residents’ bathrooms in Rm#49, Rm#47, Rm#46, Rm#16, Rm#23 and the restrooms were clean and the toilets were all working properly and did not notice any clogged drains, and the facility is properly maintained. There is not enough evidence to substantiate.

Allegation: “Staff do not ensure facility remains free of bad odors.” It is alleged that there is a strong odor from Rm#49’s bathroom on 07/02/2025. Ten (10) out of eleven (11) residents interviewed denied the allegation. One (1) out of eleven (11) residents corroborated with the allegation stated that the base of the toilet has a leak that hasn’t been fixed which is causing an odor. However, that resident and one (1) of the staff interviewed both stated that the bathroom is being cleaned daily. The Administrator also stated that the toilets in that bathroom, Rm#23, Rm#46, and other bathrooms will have their wax rings fixed on 7/8/25 which will fix the leak and remove any odors. The Administrator and all four (4) staff interviewed denied the allegation. One (1) out of four (4) staff interviewed stated that the bathroom had an odor when the toilet was clogged but there was no odor after the toilet has been unclogged and the room was aired out. Based on observation, the LPA Konishi checked and detected no bad odors in residents’ rooms and bathrooms in Rm#49, Rm#47, Rm#46, Rm#16, and Rm#23. LPA toured the physical plants including the common areas, activity room, and dining hall and did not notice any bad odors. There is not enough evidence to substantiate.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250702150727

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 07/07/2025

NARRATIVE

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Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegations 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 allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to the Administrator, Bryanna Luke.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

LIC9099 (FAS) - (06/04)

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