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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 05/10/2024
Date Signed: 05/10/2024 09:55:40 AM


Document Has Been Signed on 05/10/2024 09:55 AM - 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: 78DATE:
05/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Maria Luisa Razo - Resident Care DirectorTIME COMPLETED:
10:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management Visit to address additional information obtained during Complaint Control #28-AS-20231229081912 which was investigated by the Department’s Investigations Bureau Branch.

During interviews conducted and record review, Investigator Padilla was made aware of the following:
· There were 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 (SIR) that was submitted to CCL, it states that staff observed R1 with their right arm bleeding, and S3 arranged transportation, however, records obtained revealed that R1 called 911 for help themselves to be transported to hospital for further treatment. Facility should have submitted an addendum to their SIR to provide this updated information.
· On an unrelated incident, Investigator Padilla was informed during interviews that R2 had been without a room for 2-3 days because their roommate became aggressive with R1 and kicked R1 out of the room. This was confirmed by S4 who found R1 sleeping on the floor. During interview with R2 Investigator confirmed this information and observed R2 with a few bags in the facility hallway. S1 also confirmed that the two residents were having issues, and S1 was working on getting R2 a new room.
· There was an incident that occurred where S1 was involved in a physical altercation with R1's family member and S1 sustained injuries to their eye during the altercation, an incident report was not filed for this incident and police was called.

Based on investigation conducted by IB Investigator, along with interviews and statements with Staff and Residents, the following deficiencies listed above are being cited on the attached LIC 809-D.

LPA did not observe any health and safety concerns during today’s visit.

Exit interview was conducted, a hard copy of this report and appeal rights were provided to Maria Razo.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
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 3


Document Has Been Signed on 05/10/2024 09:55 AM - 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: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
87207

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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirment is not met evidence by:
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Licensee/Administrator to submit an addendum to their SIR and provide this updated information. A copy of this addendum/revision to be emailed to LPA by POC Due date.
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Based on IB's investigation it was determined that there were inconsistent/false statements from staff about R1's injuries and who arranged medical transportation for R1, the SIR states staff arranged transportation, however, records reveal that R1 911 for help and to be transported to hospital for further treatment.
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Type B
05/17/2024
Section Cited
CCR87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Licensee/Administrator to submit an SIR detailing incident and what was done to correct this situation, new room/roomate switch and what the facility is doing moving forward to avoid incidents between the two individuals. SIR to be submitted to LPA by POC due date.
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This requirment is not met evidence by:
During IB interview with R2 it was stated that R2 had been without a room for 2-3 days. This was confirmed by S4 who found R1 sleeping on the floor and S1 also confirmed that the two residents were having issues, and S1 was working on getting R2 a new room. IB also observed R2 with a few bags in the facility hallway.
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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 SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/10/2024 09:55 AM - 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: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Licensee/Administrator to submit an SIR detailing incident and report must also have police report number. SIR to be emailed to LPA by POC due date.
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This requirment is not met evidence by:
IB discovered there was an incident that occurred where S1 was involved in a physical altercation with R1's family member and sustained injuries to their eye during the altercation, an incident report was not filed for this incident and police was called.
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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 SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3