198603286-8-5-2025-28-AS-RORN-DKRTG2-20250821144225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/05/2025
Date Signed: 08/05/2025 11:45:38 AM

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
07/25/2025 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250725111346

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: 59	DATE:	08/05/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Bryanna Luke, Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility staff did not assist resident with obtaining medical care.
Facility staff did not dispense medications as prescribed.
Facility staff did not provide meals to resident.
Facility staff did not provide drinking water to resident.

INVESTIGATION FINDINGS:

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

On 08/01/2025, the initial investigation visit was conducted. The investigation consisted of the following:
LPA requested the Staff & Resident Roster. LPA also interviewed Resident #1 (R1) to Resident #9 (R9), the Administrator, and Staff #1 (S1) to Staff #5 (S5). LPA obtained documents from R1’s file including the face sheet, physician’s report, and special incident reports. LPA also reviewed a random sample of six (6) resident's medications.

On 08/04/2025, LPA interviewed the Resident Care Director over the phone and requested R1’s medication administration record (May 2025, June 2025, July 2025) and Wound Care Progress Notes. LPA interviewed Witness #1 (W1) over the phone.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

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-20250725111346

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: 08/05/2025

NARRATIVE

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During today's visit, LPA obtained the following documents: Staff and Client roster. LPA interviewed Witness #2 (W2) over the phone.

The investigation revealed the following: in regards to the allegation: “Facility staff did not assist resident with obtaining medical care.” It is alleged that R1 had an untreated foot infection and several medical complaints that were often ignored by staff. One (1) out of nine (9) residents interviewed corroborated with the allegation. Eight (8) out of seven (9) residents interviewed denied the allegation. The Administrator and five (5) out of five (5) staff, W1, and W2 interviewed all denied the allegation. Based on staff interview, the Resident Care Director stated that R1’s foot infection is currently being treated by a wound care nurse that visits R1 twice a week. Based on record review, the wound care progress notes confirms that the wound care nurse has visited twice a week in June 2025 and July 2025 to help treat R1’s foot. Based on the Administrator, the Resident Care Director, and the Witness #1 (W1’s) interviews, physician assistant continues to visit R1 twice a week to treat R1’s foot. Based on interview, W2 stated that the facility staff is appropriately assisting R1 in being provided medical care and also stated that there are no issues. R1 stated on waiting for an oxygen device that hasn’t been provided yet. The Administrator, Resident Care Director, and W2 stated that the oxygen concentrator has been addressed to R1’s home health care and primary care physician and currently in process of providing R1’s request of receiving the oxygen concentrator. There is not enough evidence to substantiate.

Allegation: “Facility staff did not dispense medications as prescribed.” It is alleged that the facility staff often neglected R1 for pain medication because staff believes that R1 is seeking pain medication in an attempt to get high. LPA reviewed a random sample of medications of R1 and (5) residents and all medications are given as prescribed. LPA interviewed two (2) staff that help administer and they all denied the allegation. 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 not dispensing medications as prescribed. LPA interviewed nine (9) out of nine (9) residents that receive medication management care all claim to receive all medication as prescribed from the staff and have never been administered the wrong medications by any staff managers. LPA reviewed R1's medications, Doctor’s Prescription Request, and Medication Administration Record from May 2025, June 2025, and July 2025, all medications are given as prescribed. There is not enough evidence to substantiate.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250725111346

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: 08/05/2025

NARRATIVE

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Allegations: “Facility staff did not provide meals to resident,” and “Facility staff did not provide drinking water to resident.” It is alleged that R1 is being neglected by not eating in days and staff refuse to give R1 water. The Administrator and five (5) out of five (5) staff denied the allegations stating that they provide meals and water in the dining hall or deliver the meals and water to the residents’ rooms. The administrator and three (3) out of five (5) staff interviewed stated that drinking water is available all day in the dining hall. Nine (9) out of nine (9) residents interviewed denied the allegation and stated that they are provided meals and drinking water from the facility and the staff have not refused to provide meals or water to them. One (1) out of nine (9) residents stated on buying food from outside of the facility since the resident is dissatisfied with the food being provided at the facility. 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: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

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