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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 12/02/2021
Date Signed: 12/02/2021 11:59:05 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/06/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200506135045
FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(310) 413-8717
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 43DATE:
12/02/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alex Solorio, Assistant AdministratorTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff took away resident's personal property
Resident is unable to communicate with family members
Staff unable to meet resident's needs while in care
Staff emotionally abused resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Alex Solorio and explained the reason for the visit. The initial complaint visit was conducted by LPA Rivas on 5/13/20.

The investigation consisted of the following: LPA Rivas interviewed one staff member, Resident #1 (R1), and R1's Service Coordinator. LPA Vasallo obtained R1's records including face sheet, physician's report dated 3/20/20, and medication list. LPA Vasallo also interviewed six residents and two staff.

The investigation revealed the following: Allegation Staff took away resident's personal property. It's alleged staff took R1's cellphone. R1 was interviewed and indicated staff took his/her cellphone. Staff interviewed denied the allegation. Staff indicated R1 would misplace his/her belongings and would find it a short time later. Staff confirmed R1 had a "flip phone" and would use it often. Residents interviewed did not corroborate the allegation. None of the residents indicated staff take any belongings. Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
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-20200506135045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA VILLA SENIOR LIVING
FACILITY NUMBER: 198603286
VISIT DATE: 12/02/2021
NARRATIVE
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R1's Service Coordinator indicated he/she communicated with R1 often over the phone. R1 moved out of the facility on 4/25/20 and never had a roommate. There were no witnesses to the alleged incident. Therefore, the allegation is unsubstantiated.

Allegation: Resident is unable to communicate with family members. It's alleged that at the beginning of the COVID-19 pandemic, R1 had no way to communicate with family. R1 was interviewed and indicated he/she was able to call his/her brother and sister. However, R1 did not want to provide contact information for the family to verify. Staff interviewed denied the allegation. Staff indicated facility purchased a cellphone and iPad so residents could communicate with family at the time when visits were not allowed due to the COVID-19 pandemic. Facility had a receipt for a cellphone dated 4/4/20. Staff report this cellphone was for residents to use. Residents also had access to the landline. During the visit, LPA also observed the iPad that residents can use to communicate with family. Residents interviewed confirmed facility has a cellphone and landline they can use to call friends and family. Residents also confirmed there is an iPad accessible to them also. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff unable to meet resident's needs while in care. It's alleged R1's diaper was not changed often enough. Staff interviewed denied the allegation. Staff indicated on several occasions R1 did not want staff to care for him/her. Staff report that R1 would yell at staff and would tell staff to leave the room. Residents interviewed did not corroborate the allegation. Residents did not have anything negative to report regarding staff. R1 moved out on 4/25/20 after only living at the facility for 1 month. There is no evidence that R1 suffered any adverse affects from not having diapers changed. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff emotionally abused resident while in care. The details of this allegation are unclear. R1 was interviewed and did not provide any details about the allegation. Staff interviewed denied the allegation. Residents interviewed did not corroborate the allegation. Residents did not report anything negative about the staff. The allegation is vague and there was no evidence to prove the allegation. Therefore, the allegation is unsubstantiated.

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 held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2