198603286-3-7-2024-28-AS-DSIS-D5GS5G-20240521133418

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:52:43 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
03/04/2024 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240304095151

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:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Alexander Solorio		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff were not aware of resident's whereabouts.
Staff did not follow reporting requirements.

INVESTIGATION FINDINGS:

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Licensing Program Anlayst (LPA) Wong conducted an initial 10 days visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 (Receptionist) Scarlett Munoz who allowed entry into the facility and was later met by Assistant Administrator Alexander Solorio who assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed the assistant administrator, three staff (S1-S3) and seven residents in the facility, LPA spoke to one staff (S4) via telephone and obtained resident roster, documents about Resident#1 (R1) which include: Face sheet, physician report, admission agreement, needs and service plan, incident report for R1 on 3/1/24, 1/10/24 and 1/20/24 and resident sign out sheet.

See LIC 9099C for continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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-20240304095151

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: 03/07/2024

NARRATIVE

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The investigation revealed of the following: Allegation#1 "Staff were not aware of resident's whereabouts." It's alleged staff were unaware that R1 had left the facility in the middle of the night. LPA interviewed seven (7) residents and all denied the allegation and reported they usually let staff know when they leave from the facility. Staff was aware of where they are going. LPA interviewed staff and denied the allegation. Staff reported they always do the round check in the facility. Once they found out resident was not in the room or the facility and they would report to the office and the office staff would check the camera and see if the resident left from the facility through the back door. The assistant administrator stated the facility is not a locked facility and the resident has the right to go in and out from the facility. For R1 and R1 is able to go out without any assistance. R1 usually did not sign out from the facility or would not let staff know when she's out in the facility but staff knew R1 was gone as they did the room check and they would report to the office or assistant administrator. In addition, some staff did see R1 was around the facility area and they encouraged R1 to be back to the facility but R1 was refused to go back.

Allegation#2 "Staff did not follow reporting requirements." It's alleged that the facility did not file any missing person report while R1 had left the facility " LPA interviewed the assistant administrator and reported it's been a pattern for R1 lately which R1 had been in and out from the facility. For the incident on 3/1/24, R1 was left the facility at around 2:30pm on 3/1/24 and staff received a call from hospital before 7am and indicated R1 was at the hospital. The assistant administrator stated R1 hasn't gone for 24 hours yet and therefore they did not file any missing person report. In addition, the assistant administrator reported staff would drive around the area to locate R1 and staff saw R1 was safe and coherent and they would also encourage R1 to be back in the but R1 was refused to go back to the facility.

Based on the interviews with staff and residents and documents reviewed, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to Alex Solorio.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

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