198603286-12-5-2024-28-AS-RORN-DBW2F2-20241212162049

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 12/05/2024
Date Signed: 12/05/2024 02:49:07 PM

Unsubstantiated

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
12/03/2024 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241203130303

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: 75	DATE:	12/05/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Resident Care Director Maria Razo		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not clean residents room properly
Staff do not safeguard residents personal property

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit regarding the above stated allegations. LPA met with Resident Care Director Maria Razo and explained the reason for the visit.

The investigation consisted of the following: LPA Trueman toured the facility's common areas, hallways and Resident R1- R7 bedrooms, obtained copies of the Staff & Resident Rosters and reviewed R1's file.
The following was submitted for R1: Face sheet, Admission Agreement, Physician's Report, Appraisal/Needs and Services Plan, and Client/Resident Personal Property and Valuables.
Interviews were conducted with Resident Care Director Maria Razo, Staff S1-S3 and Resident's R2-R7.
LPA inspected Rooms 9A, 13A, 29A, 30A, 42A, 42B, and 49B.
In regards to the allegation Staff do not clean residents room properly, based on interviews conducted, inspection of Resident Rooms 9A, 13A, 29A, 30A, 42A, 42B, and 49B and information gathered it was observed on the inspection of rooms of Resident's R1-R7 that there was no human waste underneath the

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

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-20241203130303

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: 12/05/2024

NARRATIVE

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resident beds and all the rooms had been cleaned and there wasn't any water leakage on the floors.
Interview with Resident's R2- R7 who all stated that housekeeping cleans their rooms 1x a week.
All stated that housekeeping clean all areas and does a good job. Said they do clean under the beds.
R2 stated that there was no feces or water leakage in the room. Stated that they mop the bathroom every Friday and clean the bathroom.
Interview with Resident Care Director Maria Razo, who stated that they clean rooms 1x a week. If there are accidents will do as needed. They do a deep cleaning. Said Resident R1 is combative toward staff when they go to clean up. Stated Resident R1 hit staff when they were trying to clean up a leak.
Interview with Staff S1-S3 who all stated that housekeeping follow a schedule and will clean rooms 1x a week or as needed. Said that Resident R1 has been aggressive with staff trying to hit them with mops.
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.

In regards to the allegation Staff do not safeguard residents personal property, based on interviews conducted and information gathered Resident's R2-R7 all stated that they have never had anything stolen at the facility. Resident R2 stated that R1 never told him anything was missing. Said R1 tells staff don't open the door because he doesn't want air to get in.

Review of Resident R1's file Client/Resident Personal Property and Valuables document has initials of Resident R1 in which it states I waive the right to complete this form. Admission Agreement dated 01/12/24 has initials of Resident R1 in which it states I understand that the facility cannot be held liable for items which are not inventoried. In addition the box is checked off and initialed where it states I decline to have my personal items inventoried.

Interview with Resident Care Director Maria Razo who stated that there has been no one who has issued a complaint that their property was stolen. Usually items may be misplaced and staff will help and they usually find it.

Interview with Staff S1-S3 who stated that there have not been any complaints. Also said that facility offers a lock box for money, ID cards and any personal items Also residents can purchase a safe for their room and don't have to give staff access. Staff said Resident R1 will tell them issues, but never did regarding his phone being stolen.

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.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

LIC9099 (FAS) - (06/04)

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