198603286-8-7-2026-28-AS-DSIS-DXWU7J-20260914152002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/07/2026
Date Signed: 08/07/2026 01:54:18 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
04/15/2026 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260415120053

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: 63	DATE:	08/07/2026
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Bryanna Luke, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Untrained and unqualified staff providing care to residents.
Staff worked while under the influence of alcohol.
Staff are not adhering to work schedules.
Insufficient staffing.
Facility is not meeting residents' hygiene needs.
Staff yell at residents.
Facility is not following plan of operation regarding meal time services.
Medication carts left unlocked and accessible to residents in care.
Facility not providing medications as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Daniel Konishi conducted an unannounced subsequent 10-Day complaint visit to investigate the above allegations. LPA met with Bryanna Luke, Administrator and explained the purpose of the visit.

On 4/21/2026, the initial investigation visit was conducted. The investigation consisted of the following:

LPA obtained a copy of the staff and resident rosters. LPA interviewed the Administrator, Staff #1 (S1) to Staff #4 (S4), and Resident #1 (R1) to Resident #9 (R9). LPA obtained Staff Training and other pertinent documents. LPA also reviewed a random sample of seven (7) resident's medications.

On 8/6/2026, LPA contacted the Administrator requesting documentation. LPA received the documentation from the Administrator via email on 8/6/2026.

[Continue LIC9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

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 6

Control Number 28-AS-20260415120053

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: 08/07/2026

NARRATIVE

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During today's visit, the investigation consisted of the following:

LPA obtained staff and resident rosters. LPA interviewed Staff #5 (S5), Resident #10 (R10), and Resident #11 (R11). LPA attempted to interview Resident #12 (R12) over the phone but LPA was unable to interview R12 since LPA was unable to reach R12. LPA obtained monthly staff work schedule, Staff Training, and other pertinent documents.

The investigation revealed the following: in regard to the allegation, “Untrained and unqualified staff providing care to residents.” It is alleged that the facility caregivers are inexperienced that has led to some residents suffering accidents particularly during the night shift. LPA interviewed the Administrator and five (5) out of five (5) staff that denied the allegation stating that the staff are properly trained. The Administrator and three (3) out of the five (5) staff also stated that the staff are trained through in-services, videos, webinars, in-person training, and shadow training. LPA interviewed eleven (11) out of eleven (11) residents that stated that the staff conduct their work in a proper manner providing care and services and not neglect care. LPA reviewed documentation of four (4) caregiver staff files Staff Training that included ongoing Annual twenty (20) hour training that covered topics such as Dementia Care Prior to Working with Residents, Postural Supports, Restricted Health Conditions, Hospice Care, Emergency Preparedness, Interaction of Antipsychotic Drugs, and Policy and Procedures Regarding Medications. There is not enough sufficient evidence to substantiate.

Allegation: “Staff worked while under the influence of alcohol.” It is alleged that staff are working under the influence of alcohol at the facility and that kitchen staff vomited in the sink. LPA interviewed the Administrator and five (5) out of five (5) staff that denied the allegation stating not witnessing any staff on duty under the influence of alcohol. LPA interviewed the dietary director that stated not witnessing any kitchen staff vomiting in the sink. One (1) staff stated that there are residents that appear under the influence of alcohol from consuming alcohol away from the facility. Dietary Director stated that recently one (1) kitchen staff came to work feeling ill but did not vomit and was immediately sent home. LPA interviewed eleven (11) out of eleven (11) residents that denied the allegation that stated not witnessing any staff working while under the influence of alcohol and did not witness any staff vomit at the facility. Two (2) out of eleven (11) residents stated smelling alcohol at the facility but cannot confirm if the staff is under the influence of alcohol. There is not enough sufficient evidence to substantiate. [Continue to LIC9099-C]

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 28-AS-20260415120053

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: 08/07/2026

NARRATIVE

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Allegation: “Staff are not adhering to work schedules.” It is alleged that staff are allowed to arrive late for their shifts, or to step out for smoke breaks multiple times while the staff should be working and exceeding the allotted break time limits. LPA interviewed the Administrator and five (5) out of five (5) staff that denied the allegation stating not witnessing any staff step out to take multiple smoke breaks while they should be working or exceeding their allotted time break limits. Per Administrator, there has been occasions when staff do arrive late. Administrator stated that the staff on duty would be asked to stay until the staff arrive for the next shift. However, per administrator, this has not recently occurred frequently. LPA reviewed five (5) randomly selected staff files and could not find any staff that had issues regarding arriving late to their shifts, taking multiple breaks when they should be working, or exceeding their allotted time breaks. LPA interviewed eleven (11) out of elven (11) residents that could not provide a response to this allegation since they are not sure about the staff’s work schedules. There is not enough sufficient evidence to substantiate.

Allegation: “Insufficient staffing.” It is alleged that the kitchen staff, despite lacking experience, performs the duties of a caregiver during the night shift due to a shortage of staff. LPA interviewed the Administrator and five (5) out of five (5) staff that denied the allegation stating that the facility does not have a shortage of staff. However, the Administrator and one (1) staff stated that there are staff that have been cross trained to work as caregivers. LPA reviewed two (2) kitchen staff files that included caregiver training completed that covers topics such as Repositioning, Showering/Bathing, Lifting, Transferring, Hoyer Lift Technique, Incontinent Care, Dressing and Grooming, and Special Diets. LPA interviewed eleven(11) out of eleven (11) residents that denied the allegation stating that the facility is not short-staffed and that their care needs are met and provided assistance by staff. LPA reviewed the facility’s work schedule which revealed that there are at least two (2) caregivers and (1) med tech from 6:30am to 2:30pm, two (2) caregivers and one (1) med tech from 2:30pm to 10:30pm, and two (2) caregivers from 10:30pm to 6:30am. LPA reviewed the facility’s work schedule which also revealed there is two (two) kitchen staff from 6:00am to 2:00pm, one (1) kitchen staff from 10:30am to 6:30pm, and one (1) kitchen staff from 11:00am to 7:00pm. There is not enough sufficient evidence to substantiate.

[Continue to LIC9099-C]

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 28-AS-20260415120053

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: 08/07/2026

NARRATIVE

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Allegation: “Facility is not meeting residents' hygiene needs.” It is alleged that some residents appear in the dining area in a filthy state, soiled with urine and wearing foul-smelling clothing, and at times, under the influence of alcohol. LPA interviewed the Administrator and five (5) out of five (5) staff that denied the allegation stating that residents that arrive to the dining area are not in a filthy state and do not have foul smelling clothing or under the influence of alcohol. However, the Administrator and two (2) staff also stated that before residents arrive at the dining hall in a filthy state or have a foul smell, they would kindly ask the residents if they can return to their room to help change their clothes and if necessary, help assist the resident to take a shower. LPA interviewed four (4) out of eleven (11) residents that stated observing residents that come to the dining area having a bad odor or smells of liquor. However, those three (3) residents stated that the staff help take those residents back to their room to either get changed or take a shower. LPA interviewed an additional seven (7) residents that denied the allegation stating that residents do not arrive to the dining area in a filthy state, bad odor, or smells of liquor. LPA toured the facility and observed the facility has sufficient hygiene supplies in storage. During the visit, LPA toured the facility and did not observe any residents with foul smelling clothes, in a filthy state, and under the influence of alcohol. During the visit, LPA also observed no residents arrive at the dining hall during lunch time in a filthy state, wearing foul smelling clothing, or under the influence of alcohol. There is not enough evidence to substantiate.

Allegation: “Staff yell at residents.” It is alleged that caregivers yell at residents, particularly those who do not speak English fluently. LPA interviewed the Administrator and five (5) out of five (5) staff denied the allegation stating that they have not yelled at residents, particularly those who do not speak English fluently. The Administrator and five (5) out of five (5) staff also stated not witnessing any staff yell at residents, particularly those who do not speak English fluently. One (1) staff stated that there are times when staff raise their voice for residents that are hard of hearing but do not yell at them. LPA interviewed eleven (11) out of eleven (11) residents that denied the allegation stating not being yelled at from staff and have not witnessed any staff yelling at residents, particularly those who do not speak English fluently. LPA reviewed documents of Staff In-Service Training covering Personal Rights dated 05/11/2026. There is not enough sufficient evidence to substantiate.

[Continue to LIC9099-C]

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 28-AS-20260415120053

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: 08/07/2026

NARRATIVE

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Allegation: “Facility is not following plan of operation regarding mealtime services.” It is alleged that meals, including breakfast, lunch, and dinner have recently been served outside of the established schedule. LPA interviewed the Administrator and five (5) out of five (5) staff that denied the allegation stating that meals are served during their established schedule. The Dietary Director stated that breakfast is served from 7:45am to 8:05am, lunch is served from 11:45am to 12:05pm, and dinner is served from 4:45pm to 5:10pm. LPA interviewed eleven (11) out of eleven (11) residents that denied the allegation stating that the meals are served at their established schedule. LPA also observed lunch being served during the visit from 11:50am to 12:15pm and observed meals being served to all residents in the dining room during that time. LPA also observed the caregivers receive disposable meals that were taken to residents’ rooms from the kitchen at 12:05pm. There is not enough sufficient evidence to substantiate.

Allegation: “Medication carts left unlocked and accessible to residents in care.” It is alleged that the medication cart is left unattended in common areas. LPA interviewed the Administrator, five (5) out of five (5) staff that denied the allegation stating that the medications are kept locked and inaccessible to residents when mech techs are passing medications to residents. LPA interviewed eleven (11) out of eleven (11) residents that denied the allegation stating not observing the medication cart being kept unlocked or unattended by staff. During the visit, LPA also observed medication cart in the hallway and confirmed being locked while med techs were passing medications to the residents. During the visit, LPA also observed that the medication cart was locked and near the med tech when the med tech was passing medications to residents at the dining hall during lunch. When LPA was reviewing seven (7) residents’ medications, the medication carts were also located in a secure and locked medication room which is inaccessible to clients. There is not enough evidence to substantiate.

Allegation: “Facility not providing medications as prescribed.” It is alleged that the staff fail to ensure that residents actually take their prescribed medications, as they are often simply left sitting on the table. LPA interviewed the Administrator and five (5) out of five (5) staff that denied the allegation stating medications are administered to residents as prescribed and medications are not left sitting on the table. LPA interviewed eleven (11) out of eleven (11) residents that denied the allegation stating receiving medications from staff as prescribed and have also not witnessed any medications left on the dining room tables. During the visit, LPA observed a med tech pass medications during lunch time and observed no medications left on the dining room tables. [Continue to LIC9099-C]

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 28-AS-20260415120053

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: 08/07/2026

NARRATIVE

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LPA also reviewed a random sample of seven (7) resident's medications and confirmed medications are given as prescribed and there were no issues. There is not enough sufficient evidence to substantiate.

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 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.

Exit interview was held, and a copy of this report was provided to the Administrator, Bryanna Luke.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

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