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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 05/15/2026
Date Signed: 05/15/2026 02:02:33 PM

Substantiated


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
05/11/2026 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260511094421
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: 68DATE:
05/15/2026
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Bryanna Luke, AdministratorTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Staff did not ensure medications were dispensed in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegations. The purpose of the visit was explained to med-tech Christian Solorio. Administrator Bryanna Luke arrived later.

The investigation consisted of: A physical plant tour of the facility common areas, resident rooms, and medication room was completed. Resident (R1 & R2's) medications were audited. R1's Medication Administration Records (MARs) for months March 2026- May 2026 were reviewed. Staff (S1- S3) and residents (R1- R9) were interviewed. Copies of R1's Medication Administration Records (MARs), Physician's Report, pharmacy email, physician order (5/9/26) and resident and staff rosters were reviewed and obtained.


*Report continuation on 9099C.




Reviewed R1's medications
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
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 3
Control Number 28-AS-20260511094421
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: 05/15/2026
NARRATIVE
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Allegation: Staff did not ensure medications were dispensed in a timely manner. The complaint alleges that on the evening of May 10, 2026 med-techs did not administer resident (R1's) bedtime medication Trazodone, or PRN medication Ibuprofen. According to information obtained, R1 was in pain and had difficulty sleeping without the medications. A total of nine (9) residents were interviewed. Three (3) out the nine (9) residents stated their medications are sometimes not administered on time. A resident stated a new medication was ordered, but has not been filled. Staff were informed and are looking into the concern.
A total of three (3) staff were interviewed. Staff stated the facility does not have electronic Medication Administration Records (MARs). Therefore, a pharmacy provides monthly copies of resident MARs. Staff stated that sometimes residents move in without MAR records, and med-techs use a blank facility MAR to document the resident(s) medications. Resident (R1) moved in on March 17, 2026. Staff was unable to recall if their medications were documented on a blank MAR, and did not find a record of R1's March 2026 MAR. Administration reached out to the pharmacy, but they were unable to provide a historical MAR.

Resident (R1) & R2's) medications and MAR records were reviewed during the visit. Based on observation, (R1's) May medications showed discrepancies. April 2026 and May 2026 MARs have listed PRN medication Ibuprofen 400 mg and PRN medication Simethicone 80 mg, but the medication bottles dosage did not match the pharmacy MAR. For instance, the med room has two bottles of Ibuprofen 200 mg, physician order states one PRN tablet of Ibuprofen 400 mg every 6 hours. No records were found or provided that demonstrates staff are aware of the dosage discrepancy. Per records, Ibuprofen 400 mg was not administered at all in the months of April 2026 and May 2026. Additionally, a new medication (Trazodone 25 mg) was ordered and delivered on 5/9/2026. However, based on observation the bubble pack showed Trazodone was popped and administered on 5/9/2026 and 5/10/2026, but MAR records do not have any medication technician initials, and staff cannot determine if the medication was in fact administered. The findings indicate there is sufficient information to corroborate the allegation.

Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency was cited.

An exit interview was conducted, copy of the report and appeal rights was provided to Administrator Bryanna Luke.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20260511094421
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: 05/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2026
Section Cited
CCR
87465(b)
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Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.
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Administrator agrees to:
1. Submit a written plan by tomorrow.
1. Submit proof of staff training by 5/22/26.
2. Submit a written plan that addresses centrally stored record keeping/inventory protocols, refill procedures, and facility auditing of medications.
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Based on record review, evening med-tech staff did not dispense R1's Ibuprofen 400 mg and Trazodone 25 mg on May 9, 2026 & May 10, 2026 per MD order and PRN medication request. Bubble pack shows Trazodone was popped on 5/9/26 and 5/10/26, but staff did not initial MAR, and Ibuprofen was not administered, which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3