198603286-8-23-2024-28-AS-RORN-D8YM6W-20240910092037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/23/2024
Date Signed: 08/23/2024 04:04:18 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
08/18/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240818225123

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: 77	DATE:	08/23/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not prevent the residents from engaging in a physical altercation.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced complaint visit regarding the above stated allegation. LPAs met with Assistant Administrator, Alexander Solorio and explained the reason for the visit.

The investigation consisted of the following: LPAs conducted a tour of the facility’s common areas, obtained copies of the Resident & Staff Rosters, House rules, In service training log Residents rights, Incident Report dated 8/17/2024 and Police report information. LPAs reviewed and obtained files for Resident #1 (R1) – Resident #2 (R2) such as: Identification and Emergency Information Sheets, Admission agreements, Physician Reports, Personal Rights, Preplacement Appraisal Information, Appraisal Needs and Services Plans. LPAs interviewed Resident #1 - Resident #10 (R10) and Staff #1 (S1) - Staff #6 (S6).

*****CONITNUED 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: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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-20240818225123

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: 08/23/2024

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: "Staff did not prevent the residents from engaging in a physical altercation.” It is alleged that R1-R2 were involved in a verbal argument in the common area that led to physical altercation and was broken up by staff. Interviews conducted with (6) of (6) staff all denied the allegation. S4 witnessed the incident as she was in the dining area when it happened and separated R1-R2 immediately. S4 took R1 to the front office and administered first aid. Some staff interviewed indicated that R1-R2 did not suffer major injuries and did not require hospitalization. S1 and S3 attended to R2 right away to check his condition and interviewed him regarding the incident. S5 stated that he was in the kitchen and intervened as soon as he heard the commotion in the dining room. All staff interviewed indicated that they do not allow any type of altercations or harassments among residents in the facility. R1-R2 admitted being involved in the altercation but stated that the staff intervened right away and separated them. R1-R2 indicated that none of them were desirous of prosecution and refused to be sent to the hospital. All residents interviewed denied the allegation and indicated that facility staff immediately intervene if they see or hear any altercations among the residents. 10 out of 10 residents interviewed stated that they feel safe and comfortable.

Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation.

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 allegation is UNSUBSTANTIATED.

Exit interview and a copy of this report was provided to Alexander Solorio, Assistant Administrator.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC9099 (FAS) - (06/04)

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