198603286-3-14-2024-28-AS-WSHO-D3GTA5-20240318143257

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:21:21 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
03/05/2024 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240305093601

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: 80	DATE:	03/14/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Alexander Solorio		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent resident from hitting another resident in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial 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 & resident rosters, interviewed Assistant Administrator, Staff 1 - Staff 2 (S1 - S2) and Resident 1 - Resident 8 (R1 - R8). LPA obtained copies of the Unusual Incident/Injury Report, SOC 341 and police report.

The investigation revealed the following: regarding the allegation "staff did not prevent resident from hitting another resident in care", it is alleged that R2 went into R1's room and hit R1's arm with a stick. Administrator and staff stated that they did not witness R2 hitting R1 with the stick, but R2 did go in R1's room and was immediately removed from the room. Staff stated that they did not see any visible injuries or bruises on R1's arm. The police officer that responded to the incident also did not see any visible injuries or observed that R1 was in pain. (Continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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 2

Control Number 28-AS-20240305093601

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: 03/14/2024

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
26
27
28
29
30
31
32

R1 stated that R2 came into the room and grabbed a stick that R1 keeps in the room and hit R1's arm. R1 also stated that R2 did not hit R1 hard and that staff rushed in the room and removed R2 from the room. R1 stated that it is not the staff fault because this happened very suddenly and it was unpredictable. R2 stated that R2 passed by R1's room and the door was open and R1 yelled obscenities at R2. That is why R2 went inside the room and hit the bottom of the bed. R2 denied hitting R1's arm. R1 stated that there has been no further issues with R2 since that incident. Residents interviewed did not witness the incident, but stated that staff do tend to intervene quickly in this kind of matters. There is no concrete evidence that R2 hit R1. However, staff did intervene quickly and prevented any major injuries.

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2