198603286-4-17-2024-28-AS-RORN-D4VP8Z-20240502110622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 04/04/2024
Date Signed: 04/17/2024 03:54:26 PM

Substantiated

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
12/29/2023 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231229081912

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: 83	DATE:	04/04/2024
		UNANNOUNCED	TIME BEGAN:	02:18 PM
MET WITH:	Alex Solorio - Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility failed to seek medical attention for resident's wounds.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit regarding the above allegation. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit.

The investigation consited the following: During visit the initial visit dated 01/05/2024 LPA toured facility, dining room, various resident bedrooms, and obtained copies of resident and staff rosters, LPA did not observe any immediate health and/or safety concerns during visit and investigation needed further investigation.

During todays visit 4/4/24 LPA obtained copies of resident and staff rosters and delievered findings.

(Continued on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

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-20231229081912

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: 04/04/2024

NARRATIVE

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The investigation revealed the following:
Allegation: Facility failed to seek medical attention for resident's wounds.
It is alleged that R1 had wounds on their finger, arms & legs that have gone untreated. This allegation was investigated by Investigator Padilla with the Investigations Branch (IB). Victim, witnesses, and staff member interviews were conducted. The following information was found during IB's investigation: The caregivers, MedTech's, and administration staff failed to seek timely medical attention for R1 on 12/26/2023 which resulted in R1 seeking their own medical treatment by calling 911, after R1 informed multiple facility employees that they had injuries on their finger, arm, and leg. R1 was diagnosed at the local hospital with swelling of the right hand and index finger that had redness, swelling, and drainage as a result of an unwitnessed mechanical slip and fall. Hospital medical records for R1 state: that there were signs of Suspected Abuse and Neglect. Per IB report by investigator: There were too many inconsistent and false statements from both S1 and S2 about the accounts of R1's injuries
and who arranged medical transportation for R1. On the Unusual Incident/Injury Report, it states that staff observed R1 with their right arm bleeding, and MedTech S3 arranged transportation. The document has false information, S3 did not arrange transportation for R1. R1 called 911 for help and to be transported to local Hospital for further treatment.

Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation 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 held and a copy of this report was provided along with appeal rights to Alex Solorio.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20231229081912

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: 04/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/18/2024 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator will review the Title 22 Regulations and ensure that and all staff will provide the necessary attention to residents who require medical attention and provide assistance in providing transportation to the nearest available medical facility.
	8 9 10 11 12 13 14	R1 needing medical attention after sustaining injuries to the right hand and index finger that had redness, swelling, and drainage as a result of an unwitnessed slip and fall, R1 called emergency transportation for treatment themselves on 12/26/23.	8 9 10 11 12 13 14	The administrator will send a copy of the in-service training and log with participants signature by POC due date to LPA via email.
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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 Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024

LIC9099 (FAS) - (06/04)

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