198603286-4-30-2024-28-AS-DSIS-D5CTNL-20240517145255

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 04/30/2024
Date Signed: 04/30/2024 03:56:52 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
03/29/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240329134905

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: 78	DATE:	04/30/2024
		UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Maria Luisa Razo - Resident Care Director		TIME COMPLETED:	02:43 PM

ALLEGATION(S):

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Staff allowed resident to be left in soiled clothing for an extended period.
Staff do not ensure that residents are adequately fed while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to continue investigating the above allegations. LPA met with Maria Luisa Razo, Resident Care Director and discussed the purpose of today's visit.

During the initial visit conducted on 04/05/2024, LPAs B. Pena and D. Konishi obtained copies of Resident & Staff Rosters and Resident #1 (R1) files such as: Face sheet, Admission's Agreement, Preplacement Appraisal and Personal Rights. LPAs conducted a walk through of the facility, which included, but not limted to the resident bedrooms. LPAs also interviewed Staff #1 (S1) - Staff #2 (S2).

During today's visit, the investigation consisted of the following: LPA B. Pena obtained copies of Resident & Staff Rosters, R1's Hospice records/notes and Physician's report, and Staff shift to shift report. LPA interviewed Staff #3 (S3) - Staff #5 (S5), Resident #2 (R2) - Resident #10 (R10). Resident #1 (R1) was transferred to a Skilled Nursing Facility (SNF) after hospitalization, therefore not interviewed.
******CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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-20240329134905

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: 04/30/2024

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: "Staff allowed resident to be left in soiled clothing for extended periods of time." It is alleged that the resident was left in soiled clothing on 03/28/2024. All staff interviewed stated that the caregivers do their rounds 2-3x during their shift. Staff stated that incontinent residents are changed daily and bedridden residents are given priority on diaper changes. Staff stated that they did not receive complaints from any resident or responsible parties about incontinence care. A total of nine (9) residents were interviewed, of which (2) residents indicated that they heard residents not being attended or changed diapers as needed. (2) out of (9) residents stated that they heard incontinent residents call and yell for assistance and had to wait before receiving incontinence care. LPA reviewed the records indicating that R1 who wears catheter was on the diaper change list on 3/28/2024 and staff completed the work prior to R1 being transferred to the hospital. Documentation reviewed, and interviews conducted do not corroborate this allegation.

In regards to the allegation: "Staff do not ensure that residents are adequately fed while in care." It is alleged that the resident did not receive breakfast. No other details were provided. (5) of (5) staff interviewed stated that residents are aware of the meal schedule and have not received complained that residents were not adequately fed. Staff stated that bedridden residents automatically have their meals delivered to their rooms by the staff who also assist with feeding. Staff indicated that residents are offered 3 meals per day and 2 snacks per day and alternative food options. Interviewed residents denied the allegation and stated that they either get their food delivered to their rooms or they go to the dining area. Residents also stated that the food is okay and facility provide them with alternative options if they don't like the food served on that day. (2) out of (9) residents indicated they are not happy with the food choices and would prefer healthier options like more vegetables. LPA toured the dining area during lunch and observed residents eating and that the food served was on the menu for the day. LPA also inspected the refrigerator and the food pantry and observed sufficient food supplies. Therefore, there is insufficient evidence to corroborate the allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided to Maria Luisa Razo, Resident Care Director.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC9099 (FAS) - (06/04)

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