198603286-9-3-2024-28-AS-DSIS-D96QXS-20240916123359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 09/03/2024
Date Signed: 09/03/2024 02:58:46 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
07/24/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240724092144

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:	09/03/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff pushed resident out of their wheelchair while in care.
Staff locked resident in their room while in care.
Staff did not safeguard resident's personal belongings while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the above stated allegations. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit.

The investigation consisted of the following: During the initial visit on 7/26/2024, LPA Pena toured the facility's common areas, hallways and Resident #1 (R1)'s bedroom, obtained copies of the Staff & Resident Rosters and R1's files such as: Face sheet, Admission Agreement, Physician's Report, Care Plan, Appraisal/Needs and Services Plan, Unusual Incident/Injury Report (Jan-Mar 2024) and 30-day eviction notice (dated 03/20/2024).

During today's visit, LPA obtained copies of Resident & Staff Rosters and conducted a tour of facility and common areas, reviewed files for Resident #1 (R1) and requested additional documents such as; R1's Personal Property and Valuables form (LIC 621), 51/50 Placement for Evaluation and Treatment form (dated 03/25/2024) and copy of the signed release form of R1's personal belongings. LPA interviewed Resident #1 (R1) - Resident #10 (R10) and Staff #1 (S1) - Staff #5 (S5). *****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: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

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-20240724092144

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: 09/03/2024

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: "Staff pushed resident out of their wheelchair while in care." It is alleged that R1 was pushed out of her wheelchair. No other information provided. Interviews conducted with (5) of (5) staff all denied the allegation. Staff interviewed indicated that they have never pushed any resident, nor have they observed any other staff push any of the residents out of their wheelchair. Staff stated that if they observe residents needing help, they assist in pushing the residents' wheelchair with their consent. (10) of (10) residents interviewed denied the allegation and indicated that staff treat them with dignity, and they feel safe at the facility. (5) out of (10) interviewed residents use wheelchair and stated that they were never pushed out of their wheelchair nor observed any staff push any of the residents out of their wheelchair. Therefore, there was insufficient evidence to corroborate with the allegation.

In regards to the allegation: “Staff locked resident in their room while in care.” It is alleged that R1 was locked into the room and that staff would tie the bedroom's doorknob to a metal railing with a sheet so R1 could not get out, and was left there for hours. (5) out of (5) staff interviewed denied the allegation. Staff interviewed stated that they would never lock any resident in their bedroom as it is against the law and a violation of the residents rights. (10) out of (10) interviewed residents denied the allegation. Interviewed residents stated that they have never been locked in their bedrooms by staff nor have seen any other residents being locked in their bedrooms. During the visit, LPA tested R1's bedroom door lock and observed that R1's bedroom cannot be locked from the outside. LPA also observed that there is a sliding door in R1's bedroom that leads to the back patio area and can be used as entrance/exit to R1's bedroom. Additionally, LPA did not observe any metal railing near R1's bedroom door. Therefore, there was insufficient evidence to corroborate with the allegation.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240724092144

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: 09/03/2024

NARRATIVE

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In regards to the allegation: "Staff did not safeguard resident's personal belongings while in care." It is alleged that the facility staff kept R1's belongings and was only given (5) bags of donated clothes when R1 left the facility. (5) out of (5) staff interviewed denied the allegation. S1 stated that if a resident leave the facility for a long period of time, the residents' belongings are kept in their bedrooms until they get confirmation that the resident is not coming back to the facility. Staff indicated that they pack, label, hold and store the residents' belongings in the storage room until the resident or family member is ready to pick them up. (10) out of (10) interviewed residents stated that they do not have any issues with their personal belongings. Interviewed residents indicated that they feel that their personal belongings are safe in their bedrooms. Reviewed documentation showed that upon moving in, R1 waived her right to complete a personal inventory list. Documentation reviewed and interviews conducted do not corroborate this allegation.

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.

An exit interview was conducted, 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: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC9099 (FAS) - (06/04)

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