198603286-7-15-2025-28-AS-DSIS-DKCS3U-20250808133142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/15/2025
Date Signed: 07/15/2025 04:07:46 PM

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
07/07/2025 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250707160124

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: 58	DATE:	07/15/2025
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Bryanna Luke, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff are not ensuring that the residents have a place for their belongings.
Facility staff are not ensuring that residents have working water.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted an Initial 10-Day complaint investigation visit regarding the above allegations. The LPA discussed the purpose of the visit with Administrator, Bryanna Luke.

The investigation consisted of the following: LPA requested the Staff & Resident Roster. LPA also interviewed Resident #1 (R1) to Resident #6 (R6), the Administrator, and Staff #1 (S1) to Staff #4 (S4), and the maintenance handyman. LPA obtained documents from R1’s file including face sheet, physician’s report, and special incident reports.

[Continued in LIC-9099-C]

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

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 3

Control Number 28-AS-20250707160124

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: 07/15/2025

NARRATIVE

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The investigation revealed the following: in regard to the allegation, “Facility staff are not ensuring that the residents have a place for their belongings.", it is alleged that R1’s dresser has been broken since April 2025. R1 was informed that the facility will replace the dresser but has not yet been replaced so residents place the belongings on the bed. Six (6) out of six (6) residents interviewed denied the allegation. However, based on resident’s interview, R1 stated that the dresser is not broken but asked for an additional dresser which the resident is waiting to receive from the facility. The Administrator and all four (4) staff interviewed denied the allegation and stated that R1 did not report a broken dresser. Based on the administrator, and one (1) out of four (4) staff interviewed, R1 does not have a broken dresser but asked for an additional dresser since R1 has additional belongings. Based on the interview, the administrator stated that the facility currently provides one (1) dresser. During the physical plant tour, LPA Konishi inspected the dressers in several different resident rooms at random. LPA inspected room #7, Room #8, Room #10, Room #16, Room #21, Room #24, and Room #42 and observed the dressers to be in good condition. Therefore, there is not enough evidence to substantiate the allegation.

In regard to the allegation: “Facility staff are not ensuring that residents have working water.” It is alleged that the water on the first floor of the facility has not been working since April 2025, which has required the residents to use the water hose outside to brush their teeth. Five (5) out of six (6) residents interviewed denied the allegation and stated that when the water was shut off it was temporary as the facility was working on plumbing or water-related repairs which only took a few hours to complete. One (1) out of six (6) residents interviewed corroborated with the allegation stating that when the resident’s faucet was being repaired, the resident was unable to go to the alternate restrooms since the door was locked so the resident would use the outdoor hose. The administrator and all four (4) staff interviewed denied the allegation. Based on interview, the administrator stated that the date of the sink not working in R1’s room was reported on 06/18/2025. The administrator stated that the sink in R1’s room was completely repaired and working on 07/09/2025. The administrator and the Maintenance handyman both stated that they were waiting for additional parts to arrive to complete the repair. While the repair was in progress, the administrator stated that R1 had access to multiple bathrooms that were unlocked and near R1’s bedroom. The administrator stated that if the bathroom door was locked, it’s either the bathroom was occupied or the residents can contact the staff to unlock the door. Based on record review, LPA obtained a Special Incident Report dated 06/09/2025, the facility had the water temporarily shut off from 9am to 1pm due to an emergency leak on 06/09/2025.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250707160124

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: 07/15/2025

NARRATIVE

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During the physical plant tour, LPA Konishi checked that the bathroom faucets and toilets were working properly in Room#7, Room#8, Room#10, Room#16, Room#21, Room#24, Room#42. LPA also toured the alternate bathroom that the residents have access to and observed that the door is unlocked and available to be used. Therefore, there is not enough evidence to substantiate.

Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported 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 allegations are UNSUBSTANTIATED.

An exit interview was held, and a copy of this report was provided to the Resident Care Director, Maria Razo.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

LIC9099 (FAS) - (06/04)

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