<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 03/19/2024
Date Signed: 03/19/2024 02:20:09 PM


Document Has Been Signed on 03/19/2024 02:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 81DATE:
03/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:48 AM
MET WITH:Alexander Solorio - Assistant AdministratorTIME COMPLETED:
02:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Bennette Pena and Christian Gutierrez conducted an unannounced Case Management Visit to follow up on the Death Report of a Resident faxed to the Department on 03/16/2024. LPAs were met by Alexander Solorio, Assistant Administrator and explained the reason for the visit. Facility reported that around 6:30am on 03/12/2024, a staff noticed the resident/R1 (Robert Polinsky DOB 10/22/1969) sleeping. At around 9am, a staff was conducting med rounds and found R1 unresponsive and had no pulse. The staff called 911, paramedics arrived, checked R1's pulse and declared R1’s time of death at 9:07am. The cause of death is yet to be determined, awaiting autopsy from mortuary as indicated in the death report submitted by the facility.

During today's visit LPAs interviewed the Asst. Administrator/S1. S1 stated that he received a call from a staff on Tue., 3/12/2024 regarding R1 who was unresponsive. S1 instructed the staff to call 911 immediately. Paramedics arrived and checked R1's pulse and declared him dead. Pasadena Police came and interviewed the staff members present.

Prior to today’s visit, LPA Pena obtained copies of Staff and Resident rosters, House Rules, R1’s files such as Face Sheet, Death Report, Admission Agreement, Appraisal/Needs & Services Plan, Physician's Report, Medication Administration Record (MAR) for Jan 2024-Mar 2024, and Pasadena Police Report information (24-19553). No concerns, obstructions, or anything out of the ordinary was witnessed during the visit. LPAs also requested the facility to obtain and provide Licensing with R1’s Death Certificate upon receipt if available.

Deficiency observed during today's visit and cited on LIC809-D. An exit interview was held and a copy of the report was provided to Alexander Solorio, Administrator.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/19/2024 02:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
87506(a)

1
2
3
4
5
6
7
87506 Resident Records...(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Assistant Administrator shall ensure that the Medication Administration Records (MARs) are accurate for all residents. The Assistant Administrator agreed to submit a plan of correction to avoid improper documentation of Medication Administration Record (MAR) and prevent medication errors.
8
9
10
11
12
13
14
Based on interviews and review of documentation, R1's Medication Administration Record (MAR) for March 2024 is inaccurate. MAR for March 2024 shows that 2 staff initialed the medication log from 3/12/2024-3/16/2024 even after R1’s passing which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Additionally, all facility staff in charge of medication management shall be re-trained on Medication Management & proper documentation. A copy of the in-service training form along with topics discussed and signatures of staff present will be submitted to CCL/LPA by the POC due date.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2