198603286-7-26-2024-28-AS-DSIS-D7USLS-20240805135850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/26/2024
Date Signed: 07/26/2024 01:52:09 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
05/20/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240520102446

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: 74	DATE:	07/26/2024
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Alexander Solorio - Asst. Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff do not frequently change a resident while in care.
Staff are not meeting a resident's hygiene needs.
Staff did not provide cold water to a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit for the allegations listed above. LPA Pena met with Assistant Administrator Alexander Solorio and explained the purpose of the visit.

During the initial visit on 05/21/2024, LPAs B. Pena and D. Konishi conducted a tour of the facility’s common areas focusing on R1's bedroom, checked water temperature in the community shower room, and checked hygiene/bathing/incontinent supplies. LPAs obtained copies of Resident & Staff Rosters, Resident #1 (R1) files such as: Face sheet, Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Service Tracker, Hospice Records, Shift to Shift Notes (Apr. 2024). LPAs also interviewed Staff #1 (S1) and Nurse #1 (N1).

During today’s visit, LPA Pena obtained Resident & Staff Rosters, police report information, Hospice Records (Apr-May 2024), Shift to Shift Notes (May 2024) and Home Health Notes (April-May 2024). LPA also interviewed Staff #2 (S2) – Staff #6 (S6) and Resident #2 (R2) – Resident #8 (R8).
*****REPORT 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: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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 3

Control Number 28-AS-20240520102446

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: 07/26/2024

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: “Staff do not frequently change a resident while in care.” It is alleged that a resident was not being changed. No other information provided. (6) out of (6) staff interviewed denied the allegation and stated that incontinent residents are being changed on a regular basis. S1-S2 stated that they have incontinent schedule/service tracker that’s updated daily. Staff interviewed stated that they have adequate staffing, (2) caregivers per shift plus a 3rd mid shift caregiver. Caregivers follow the service tracker schedule that is provided to them before their shift starts. Some staff interviewed indicated that they monitor the residents and check on them every 2-3 hours or as needed. (6) out of (8) incontinent residents interviewed stated that the staff change them frequently and have not been left throughout the day or overnight without changing undergarments. Residents interviewed stated that staff assist them when they ask for help. Records reviewed revealed that logs are maintained and staff record notes of the care provided to the residents during their shift, whether it's changing undergarments, delivering food or giving the residents a shower. Therefore, there was insufficient evidence to corroborate with this allegation.

In regards to the allegation: "Staff are not meeting a resident's hygiene needs." It is alleged that a resident was filthy, no one assists with hygiene and only receives a quick and inadequate bed bath from hospice weekly and no other showers/baths. (6) out of (6) staff interviewed denied the allegation and stated that caregivers have a schedule that they follow during their shifts. Facility maintains a daily service tracker, shift to shift report and shower schedule that lists the residents needing assistance in hygiene and shower. Staff interviewed stated that they assist residents with changing clothes, brushing their teeth, feeding and
showering. Staff indicated that they give residents a shower 2-3x a week and recorded on the service tracker and shift to shift notes once finished. S2 states that if home health care provides bathing services to a resident, the staff still step in to shower or bathe the resident in between the home health visits. During the visit on 5/21/2024, N1 stated that R1 is being provided bed bath once a week and indicated that hygiene supplies are provided by the facility. LPAs also observed sufficient hygiene supplies stored in the Administration office which are provided to the residents. Records reviewed revealed that R1 is provided shower service by a home health aide and the facility staff. Therefore, there was insufficient evidence to corroborate with this allegation.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240520102446

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: 07/26/2024

NARRATIVE

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In regards to the allegation: "Staff did not provide cold water to a resident." It is alleged that there was no cold water in the facility. No other information provided. (6) out of (6) staff interviewed denied the allegation and stated that the facility has cold water but not hot water. Staff interviewed stated that there is no hot water due to a plumbing issue in the community shower rooms and that the water pressure was very low or water only dripped in some stalls. S1 indicated that a plumber already came and provided the estimate. (5) out of (8) residents interviewed stated that only cold water was available and there was no hot water in the shower rooms. During the visit on 5/21/2024, LPA tested the water temperature and readings were 90.8 deg F in stall #1, 98.6 deg F in stall #2 and 89.2 deg F in stall #3, all stalls were in the large community shower room. LPA observed that there was no hot water and a deficiency was issued on a separate case management report.

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 and a copy of this report was provided to Alexander Solorio, Asst. Administrator.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC9099 (FAS) - (06/04)

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