198603286-8-3-2021-28-AS-MVAO-CALV5H-20220112150758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/03/2021
Date Signed: 08/03/2021 03:39:30 PM

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
07/28/2021 and conducted by Evaluator Joe Katrdzhyan

COMPLAINT CONTROL NUMBER: 28-AS-20210728115738

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: 39	DATE:	08/03/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Assistant Administrator / Alexander Solorio		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident wandered away from the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Resident wandered away from the facility".

During today's visit, LPA interviewed the Assistant Administrator and reviewed the file of Resident #1 (R1). LPA obtained copies of the following documents in reference to R1;

• Physician's Report • Unusual Incident/Injury Report • Resident Information Sheet • Medical Reports

The investigation revealed the following;
Based on the interview conducted and file review, LPA discovered that on 7/27/21, at approximately 1PM, R1 left the facility through the side gate, located in the parking lot. Once facility staff discovered R1 went missing,

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

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-20210728115738

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: 08/03/2021

NARRATIVE

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a missing person's report was filed through the Pasadena Police Department and the brother of R1 was notified. On 7/30/21, facility staff received a call from Huntington Hospital stating R1 was found in the parking lot of Target and taken to Huntington Hospital. As of 8/3/21, R1 remains hospitalized. According to the Physician's Report dated: 9/1/2020, R1 is not able to manage own treatment, medication and equipment. R1 is listed as non-ambulatory and needs assistance with most of his activities of daily living. The treating physician has also indicated that R1 is not able to leave the facility unassisted. LPA discovered that this was the second incident involving R1 leaving the facility unassisted, without staff supervision. This presents an immediate health and safety concern for R1 as the facility was not able to provide care and supervision to meet the needs of R1.

Based on LPA’s interview conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

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

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210728115738

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/04/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2 Health and Safety Code section 1569.2(c) provides: "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing	1 2 3 4 5 6 7	Administrator shall conduct an in-service training to staff on Basic Services and provide a copy of the materials discussed along with names and signatures of staff in attendance. Administrator will also develop a written plan detailing how staff will ensure care and supervision is being provided as necessary to meet the needs of residents in care.
	8 9 10 11 12 13 14	assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement is not met as evidenced by; On 7/27/21, at approximately 1PM, R1 left the facility through the side gate, located in the parking lot. Per the Physician's Report dated: 9/1/2020, R1 is not able to manage own treatment, medication and equipment. R1 is listed as non-ambulatory and needs assistance with most of his activities of daily living and R1 is not able to leave the facility unassisted. This presents an immediate health and safety concern for R1 as the facility was not able to provide care and supervision to meet the needs of R1.	8 9 10 11 12 13 14	POC must be submitted to CCL by the POC due date of 8/4/21.
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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.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

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