198603286-11-23-2021-28-AS-MVAO-CB2UUP-20220126145351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 11/23/2021
Date Signed: 11/23/2021 02:59:13 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
12/10/2020 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201210170802

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: 42	DATE:	11/23/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Assistant Administrator Alexander Solorio		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff neglected resident.
Staff did not notice a change in resident's condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent complaint visit to the facility and was greeted by Assistant Administrator Alexander Solorio and explained the reason for the visit.
The purpose of the visit is to deliver the findings for the above allegations.
Initial visit was conducted on 12/17/2020 and interview was conducted with Wellness Nurse / Marisol Cruz Riquelme telephonically due to the situation surrounding the Coronavirus Disease 2019 (COVID-19).
Subsequent visits were conducted on 7/21/21 and 9/9/21 in which staff and resident's were interviewed.
Investigation consisted of interviews with staff, residents, hospice agency representative, social worker for Resident 1, and review of Hospice Documentation.
In regards to the allegation Staff neglected resident, based on interviews conducted and information gathered it was revealed that Resident 1 was admitted to the facility on 12/01/20. Hospice agency began service on 12/02/20 for Resident 1 which included a Plan of Care formulated to oversee activities of daily living (ADL's). A Certified Home Health Aide was assigned 2x weekly to perform ADL's care and assistance.
Hospice Representative interviewed stated that the facility acted professionally and performed their job duties

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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-20201210170802

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: 11/23/2021

NARRATIVE

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well in regards to Resident 1.
Interviews conducted with clients who said staff act quickly for residents and call 911 right away and staff does a good job helping all individuals with medication, food and arranging transportation.
Stated that staff help residents to get their needs met with showering and changing diapers.
Staff interviewed stated that there was a Care Plan and they would do changes for showers and medication management.
Hospice would do wound care.
Stated that when Resident 1 did not look well staff reacted immediately to get help.
Social Worker for Resident 1 did confirm that Resident was at facility for 6 days and then went to the hospital. Stated that she did communicate with the facility on the health status of Resident 1.
It should be noted that Hospice was overseeing Resident 1 from 12/2/20 to 12/07/20. Resident 1 entered hospital on 12/7/20 and did not return to the facility.
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.

In regards to the allegation Staff did not notice a change in resident's condition, based on interviews conducted and information gathered Resident 1 had a Plan of Care from Hospice between 12/02/20 and 12/07/20 in which all ADL's were overseen with 2x weekly performing Care and Assistance as assigned by RN Supervisor Plan of Care.
Hospice Agency representative stated that facility carried out their job duties professionally and did a good job.
Interviews conducted with clients who said staff act quickly for residents and call 911 right away and staff does a good job helping all individuals with medication, food and arranging transportation.
Stated that staff help residents to get their needs met with showering and changing diapers.
Staff interviewed stated that there was a Care Plan and they would do changes for showers and medication management.
Staff acted immediately when Resident 1 was not looking well and called 911.
Social Worker for Resident 1 did confirm that Resident was at facility for 6 days and then went to the hospital. Stated that she did communicate with the facility on the health status of Resident 1.
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.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC9099 (FAS) - (06/04)

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