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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 09/01/2021
Date Signed: 09/01/2021 03:34:58 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
07/06/2021 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210706094631
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: 31DATE:
09/01/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not administer medications as prescribed

There is a strong odor of marijuana present inside the facility

Facility has inadequate staffing for the residents while in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nune Margaryan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegations of "Staff did not administer medications as prescribed, There is a strong odor of marijuana present inside the facility and Facility has inadequate staffing for the residents while in care". Upon arriving at the facility, LPAs met with Assistant Administrator / Alexander Solorio who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 7/7/21, in reference to the allegations listed above. During the course of the investigation, LPA interviewed the Assistant Administrator and Receptionist / Jeanette Velasquez. LPA was unable to interview Resident #1 (R1) and Staff members #1 and 2 (S1 and S2) as R1 no longer resides at this facility and S1 and S2 are no longer employed at this facility (whereabouts are unknown at this time). During the visit conducted on 7/7/21, LPA toured the facility smoking and non-smoking areas. LPA also obtained and reviewed copies of the following documents in reference to the allegations listed above;
• Written statement from S1 regarding the incident involving R1 • Hands-on Training Record for S1
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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 5
Control Number 28-AS-20210706094631
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: 09/01/2021
NARRATIVE
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• New Hire Initial Training Record for S1 • R1 Information Sheet • Physician's Report for R1 • Preplacement Appraisal Information for R1 • Personnel Record for S1 • Staff and Resident.

The investigation revealed the following;

Allegations: "Staff did not administer medications as prescribed" and "Facility has inadequate staffing for the residents while in care". The details of these allegations state, R1 called 911 due to experiencing back pain. Once the Emergency Medical Services (EMS) arrived at the facility, S1 reported to EMS personnel that she was the only staff on duty with a census of 36 residents and she was not qualified to administer the necessary medications to R1.
Based on interviews conducted and record reviews, the incident involving R1 took place on 6/27/21, between the hours of 10:35PM - 11:35PM. R1 called 911 because was she experiencing back pain and had not been provided her pain medications. After reviewing the file of S1, LPA discovered that S1 did not have the qualifications and training to administer medications to residents. Interviews conducted corroborated with the information found in the file of S1. In reference to the allegation of "Facility has inadequate staffing for the residents while in care", statements obtained confirmed that S1 was the only staff member on duty at the time of the incident and in charge of providing care and supervision to 36 residents. S2 was scheduled to be on duty with S1 but was a "no call, no show" leaving S1 alone at the facility. LPA learned that S1 failed to inform Management about S2 being a "no call, no show" in a timely manner in order to find a replacement. Based on interviews conducted and record reviews, there is sufficient evidence to support the allegations of "Staff did not administer medications as prescribed" and "Facility has inadequate staffing for the residents while in care".

Allegation: "There is a strong odor of marijuana present inside the facility". During the visit conducted on 7/7/21, at 12:15PM, LPA Katrdzhyan toured the facility with the assistance of Assistant Administrator / Alexander Solorio and observed a strong odor of marijuana coming from the hallway, near the dining room area. Based on statements obtained, LPA learned that residents have been observed smoking marijuana in their rooms and the outside, near the courtyard area. Based on LPA's observation and interviews conducted, there is sufficient evidence to support the allegation of "There is a strong odor of marijuana present inside the facility".

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20210706094631
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: 09/01/2021
NARRATIVE
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of evidence standard has been met, therefore the above allegations are 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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210706094631
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: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2021
Section Cited
HSC
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
To care, supervision, and services that meet
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Administrator will review Title 22 Regulations Section 87468.2 on Additional Personal Rights of Residents in Privately Operated Facilities and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
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their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
After reviewing the file of S1, LPA discovered that S1 did not have the qualifications and training to administer medications to residents. Interviews conducted corroborated with the information found in the file of S1.
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Type B
09/15/2021
Section Cited
HSC
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
To care, supervision, and services that meet
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Administrator will review Title 22 Regulations Section 87468.2 on Additional Personal Rights of Residents in Privately Operated Facilities and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
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their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
On 6/27/21, between the hours of 10:35PM - 11:35PM, S1 was the only staff member on duty at the time of the incident and in charge of providing care and supervision to 36 residents. S2 was scheduled to be on duty with S1 but was a "no call, no show" leaving S1 alone at the facility.
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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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210706094631
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: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2021
Section Cited
HSC
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by;
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Administrator will review Title 22 Regulations Section 87468.1 on Personal Rights of Residents in All Facilities and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
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During the visit conducted on 7/7/21, at 12:15PM, LPA Katrdzhyan toured the facility with the assistance of Assistant Administrator / Alexander Solorio and observed a strong odor of marijuana coming from the hallway, near the dining room area. Based on statements obtained, LPA learned that residents have been observed smoking marijuana in their rooms and the outside, near the courtyard area.
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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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5