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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/01/2025
Date Signed: 07/03/2025 11:49:19 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/07/2024 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241007160218
FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 56DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Maria Razo, Resident Care DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff neglect resulted in resident being hospitalized for sepsis
Facility staff did not seek timely medical attention for resident
Facility staff did not respond to resident's calls for help
Facility staff did not ensure resident's dietary needs were met
Facility staff did not report incident to resident's responsible person
INVESTIGATION FINDINGS:
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On 07/01/25 Licensing Program Analyst (LPA) S Vaid made an unannounced subsequent visit to the facility to conduct further investigations, in response to the above-mentioned allegations. LPA met with the Resident Care Director Maria Razo and explained the purpose for the visit. Administrator Bryanna Luke joined shortly after. The investigation consisted of the following: Review of staff and resident rosters, tour of the physical plant with Administrator and viewed common areas and resident rooms. Interviews with staff and residents. LPA did not observe any immediate health and/or safety concerns.

On 10/08/2024, Program Analyst (LPA) Bonnie Tao made an unannounced initial visit to the facility to conduct a Health and Safety check inspection, in response to the above-mentioned allegations. LPA met with Resident Care Director Maia Louisa Razo and explained the purpose for the visit. Investigation consisted of the following: LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas with assistance of staff Maria Razo, and obtained the following documents for Residents# 1-2 (R1-R2): facility records and staff/residents’ rosters.
CONTINUED ON 9099C.....
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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 4
Control Number 28-AS-20241007160218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA VILLA SENIOR LIVING
FACILITY NUMBER: 198603286
VISIT DATE: 07/01/2025
NARRATIVE
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Regarding the allegation: Facility staff neglect resulted in resident being hospitalized for sepsis. It is alleged that facility staff failed to provide an appropriate level of supervision which resulted in the resident developing sepsis in the facility. According to staff statements (investigated by Real) Five (5) out of five (5) staff deny this allegation. The staff notified the hospice nurse and then called paramedics when hospice nurse was late to show. The staff also informed the family of the resident. Six (6) out of seven (7) residents interviewed could not collaborate the allegation. They had no knowledge. According to the family, resident was on hospice and had a history of non-compliance with dialysis. The hospice nurses and aids that saw the resident at/in the facility on a weekly basis did not observe any neglect or lack of care/supervision. A copy of Residents’ hospital records and hospice records were obtained and had no information to support the allegation. Although the allegation 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.


Regarding the allegation: Facility staff did not seek timely medical attention for resident. It is alleged that facility staff neglected to seek timely medical attention and treatment for resident in care. Resident was on hospice for heart failure. According to statements (investigated by Real) Five (5) out of five (5) staff deny this allegation. Facility staff stated, hospice staff visited the resident twice per week. Whenever the resident became ill or developed difficulty the hospice nurse was notified and instruct facility staff to administer supplemental medication, when pain did not subdue the paramedics were called and family is notified, never has the facility staff denied medical treatment for residents in care. Hospice staff interviews and documents reviewed. Hospice records confirm staff reported residents change in condition to hospice and was instructed to utilized supplemental medication, re-assessment of resident conducted by hospice nurse and called for paramedics when pain did not subside. Six (6) out of seven (7) residents interviewed could not corroborate this allegation. According to residents the staff has sought medical attention for residents when residents are in medical need. Although the allegation 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.

CONTINUED ON 9099C.......
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20241007160218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA VILLA SENIOR LIVING
FACILITY NUMBER: 198603286
VISIT DATE: 07/01/2025
NARRATIVE
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 Regarding the allegation: Facility staff did not respond to resident’s call for help. It is alleged that the facility staff did not respond to the resident’s call for help. Six (6) out of six (6) staff interviewed deny this allegation, the staff performs health and safety checks on every resident every 2 hours. Residents under hospice care are frequently checked upon depending on their needs and plan of care. Response times are 3-5 minutes after resident alerts the staff. According to staff, when the resident’ fell ill the staff would notify the hospice nurse and the resident’ would be assessed, supplemental medication would be given to the resident’ by the hospice nurse when resident complained of pain and taken to hospital when supplemental medications were not enough. On 10/02/24, resident was sent to hospital due to developing difficult medical condition, at 2am resident was having difficulty with their medical condition and staff notified the residents’ hospice agency, when hospice nurse failed to show up, the facility called for the paramedics and notified the residents POA. Six (6) out of seven (7) residents interviewed could not collaborate this allegation, according to the residents interviewed they stated the staff is always ready to help them with their health conditions and have responded to their needs for help and contacted their family when change of conditions arise and when they are hospitalized. Based on interviews conducted and records reviewed, although the allegation 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.

Regarding the allegation: Facility staff did not ensure resident’s dietary needs were met. It is alleged that the staff are not ensuring resident is getting their dietary requirements as determined by their health professionals. Accordingly, resident does not like the food served and does not eat for days, and the staff does not intervene to solve the situation. Six (6) out of six (6) staff interviewed deny the allegation. According to the staff the residents are served three meals per day along with snacks throughout the day. Residents requiring special dietary as ordered by physicians’ will be served meals prepared within dietary requirements (low sodium, puree). The facility dining offers alternative menu for those residents that do not want the regular menu food(salads/soup/sandwiches), snacks and fruits are available throughout the day. Per physicians report dated 03/14/2022, resident was on special diet. The staff states, they cannot force the resident to eat, they can only reason with the resident’ when resident’ refuses to eat and notify the residents family when this occurs. The staff notified the residents’ POA, hospice nurse(resident on hospice) and licensing department when residents’ refused medications, meals, medical treatments. Six (6) out of seven (7) residents interviewed could not collaborate this allegation. According to residents interviewed, the staff is meeting their dietary needs, residents have menu choices and snacks throughout the day. Some residents have been able to receive special meals when requested ahead of time.
CONTINUED ON 9099C.............
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20241007160218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA VILLA SENIOR LIVING
FACILITY NUMBER: 198603286
VISIT DATE: 07/01/2025
NARRATIVE
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Bedridden residents are served meals in their rooms. Staff makes meal time headcount to account for all residents served and residents that refuse meals served. Based on interviews conducted, records reviewed, and observations made although the allegation 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.

Regarding the allegation: Facility staff did not report incident to resident’s responsible person. It is alleged that the facility staff did not contact residents responsible party when resident had developed difficulty and was sent to hospital. Six (6) out of six (6) staff interviewed deny this allegation, according to the Resident Care Director each time residents that are transported to the hospital the facility staff has notified residents family /POA and incident reports are reported to the State Licensing Department. Unusual Incident reports dated 08/04/23, 09/11/23, 01/29/24 and 10/02/24 staff notified the residents’ responsible party. Six (6) out of seven (7) residents interviewed could not corroborate this allegation. According to residents interviewed, they are not privy to the reporting requirements by the facility, however residents confirmed the staff notifies their family when their condition changes and they are taken to the hospital. A few residents interviewed stated, that their families are contacted whenever changes in their health condition occurs, no matter how least serious. Based on interviews conducted and records reviewed, although the allegation 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.

An exit interview was conducted, copy of this report was given to administrator Bryanna Luke.
Conducted exit interview with Maria Razo, Resident Care Director.

LPA experiencing printer issues, amended copies will be emailed to facility.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4