198603286-12-23-2024-28-AS-RORN-DCPVUM-20250107154457

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 12/23/2024
Date Signed: 12/23/2024 05:02:57 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
07/16/2024 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240716150347

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:	12/23/2024
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Alexander Solorio - Asst. Administrator Maria Luisa Razo - Resident Care Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Due to lack of supervision, a resident physically assaulted another resident, resulting in injury and hospitalization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit in response to the above-mentioned allegation. LPA met with Alexander Solorio, Asst. Administrator and Maria Luisa Razo, Resident Care Director and explained the reason for the visit.

The investigation consisted of the following: On 7/17/2024, LPA conducted a health and safety check visit and toured the facility including the common areas. LPA obtained copies of the following documents: Staff and Resident rosters, Facility Sketch, House Rules, Staff #1 (S1) - Staff #2 (S2) files and Resident #1 (R1) - Resident #2 (R2) files such as: Identification and Emergency Information (Face Sheets), Admission Agreements, Physician Reports, Medication Logs/MARs (May 2024-July 2024), Preplacement Appraisal Information, Appraisal Needs and Services Plan, Unusual Incident/Injury Reports (SIRs) dated 7/15/2024 (initial and revised), Huntington Health Hospital Discharge records for R2 (dated 07/15/2024, in Spanish).

During today’s visit, LPA obtained copies of the Staff and Resident rosters and delivered finding.
*****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: 12/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

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-20240716150347

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: 12/23/2024

NARRATIVE

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The investigation revealed the following:

In regards to the allegation: “Due to lack of supervision, R1 physically assaulted R2 resulting in injury and hospitalization.” It is alleged that without provocation, R1 began to strike R2 in the face with his right closed fist approximately 8-10 times, R2 sustained laceration to his upper right eyebrow which required hospitalization. This investigation was completed by Investigator Patterson with the Investigations Branch. Per interviews conducted by Investigator Patterson, the physical fight was unforeseen and that the fight started in the main lobby over a light switch being turned on/off by R2. Interviews supported that the two female caregivers on duty did not physically intervene due to both residents using their walking canes as weapons to strike each other. Statements revealed that the caregivers on duty gave the residents verbal instructions to stop and that 911 was promptly called. R1 believed that neglect occurred due to him having to protect himself and because the caregivers were unable to speak English. R2 denied neglect and believed that if the caregivers had intervened, they too may have been hurt. Per review of the police report and video footage of the incident, the footage (with no sound) shows the two caregivers on duty responding within the minute of the altercation. The police investigation regarding this incident was closed due to District Attorney rejection.

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, Asst. Administrator.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024

LIC9099 (FAS) - (06/04)

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