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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/25/2025
Date Signed: 07/25/2025 02:46:24 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
06/19/2025 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250619090615
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: 58DATE:
07/25/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bryanna Luke - AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff do not treat residents equally.
Staff are mismanaging residents medication.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Bennette Pena and Gabriela Castro conducted an unannounced initial complaint visit to investigate the above allegations. LPAs met with Luisa Razo, Resident Care Directorr and explained the purpose of the visit.

The investigation consisted of the following: LPAs obtained and reviewed the staff & resident rosters, Staff in service training (Residents' Rights), Theft & Loss policy, Unusual Incident/Injury reports related to the complaint and Resident #1 (R1) files such as: Identification/Emergency Information, Admission Agreement, Appraisal Needs/Services Plan, Pre-Appraisal, Physician's Report and Resident Personal Property And Valuables. LPAs interviewed Staff #1 (S1) - Staff #4 (S4), and Resident #2 (R2) - Resident #7 (R7). LPAs attempted to speak with Resident #1 (R1) but unsuccessful due to being out in the community. *****CONTINUED ON LIC9099-C*****
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
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 5
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
06/19/2025 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250619090615

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: 58DATE:
07/25/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bryanna Luke - AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Bennette Pena and Gabriela Castro conducted an unannounced initial complaint visit to investigate the above allegations. LPAs met with Luisa Razo, Resident Care Directorr and explained the purpose of the visit. Afterwards, Bryanna Luke, Administrator arrived and assisted LPAs.

The investigation consisted of the following: LPAs obtained and reviewed the staff & resident rosters, Staff in service training (Residents' Rights), Theft & Loss policy, Unusual Incident/Injury reports related to the complaint and Resident #1 (R1) files such as: Identification/Emergency Information, Admission Agreement, Appraisal Needs/Services Plan, Pre-Appraisal, Physician's Report and Resident Personal Property And Valuables. LPAs interviewed Staff #1 (S1) - Staff #4 (S4), and Resident #2 (R2) - Resident #7 (R7). LPAs attempted to speak with Resident #1 (R1) but unsuccessful due to being out in the community. *****CONTINUED ON LIC9099-C*****
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250619090615
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: 07/25/2025
NARRATIVE
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The investigation revealed the following: In regards to the allegations "Staff did not safeguard resident's personal belongings." It is alleged that R1 noted missing personal items, and had filed a police report regarding missing items but have not heard back. (3) out of (4) staff members stated that they heard several residents complained about missing items after relocating back to the facility. Staff interviewed stated that they heard an individual trespassed and stole items while he facility was vacant. Another staff interviewed stated that they had seen residents personal belongings outside of the room, not in the bags while the facility was under renovation. (5) out of (6) residents interviewed stated that they had personal items missing like clothing, blankets, shoes. Some residents indicated that they reported it to the Administration but no action was taken. Interviewed residents also indicated that several things were still being found since they had been misplaced.

Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the Administrator, Bryanna Luke along with the Appeals Rights.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20250619090615
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2025
Section Cited
CCR
87218(a)(2)
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(a) The licensee shall ensure an adequate theft and loss program.....(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property ....The licensee shall.... made reasonable efforts to safeguard resident property ...... to meet each requirement specified in Section 1569.153.
This requirement is not met as evidenced by:
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Licensee/Administrator agreed to establish a plan to address how the facility can properly safeguard residents personal belongings during relocations and renovations. Administrator to send statement stating that they have read, reviewed and understood Title 22 Regs 87218 and submit to CCL/LPA by POC due date.
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Based on interviews, Licensee failed to safeguard residents property during the relocation due to fire which poses a potential Health, Safety, and Personal Risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250619090615
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: 07/25/2025
NARRATIVE
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The investigation revealed the following:

In regards to the allegation: "Staff do not treat residents equally." It is alleged that a resident is dissatisfied with the treatment they are receiving and believes staff may demonstrate preferential treatment toward other residents based on race. (4) out of (4) staff interviewed denied the allegation. Some staff interviewed stated that some staff members have difficulty speaking English, but it doesn't impact the care they provide to the residents. Staff interviewed stated that they ensure fair treatment of all residents, regardless of their race. (6) out of (6) residents interviewed stated that they have not seen or experienced staff treating them differently on the basis of their race. Residents interviewed stated that staff treat them fairly and interact with them regularly. Therefore there was insufficient evidence to corroborate with the allegation.

In regards to the allegation: "Staff are mismanaging residents medication." It is alleged that there are staff members covering for medication technicians who fail to bring the correct medications but the resident has not expressed any immediate safety concerns at this time. (4) out of (4) staff interviewed denied the allegation. Staff stated that there are sufficient med-techs on hand to administer medications to the residents. Staff indicated that some staff who assist med techs in passing medications have received medication training. Additionally, staff indicated that they have not received any report or complaint about mismanaging residents medication. Residents interviewed stated that while several staff members administer the medication, they are the correct medications. Residents also stated that they had never been administered the wrong medication by any staff members and have no concerns at this time. Therefore there was insufficient evidence to corroborate with the 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.

Exit interview was conducted. A copy of this report along was provided to the Administrator, Bryanna Luke.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5