198603286-7-7-2021-28-AS-MVAO-CC6TCP-20220303133703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:45:31 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
05/14/2021 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210514091631

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: 38	DATE:	07/07/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	HR Representative / Michael Murphy Assistant Administrator / Alexander Solorio		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Illegal eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Illegal eviction". Upon arriving at the facility, LPA met with HR Representative / Michael Murphy and was later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 5/21/21, in reference to the allegation listed above.

On 6/2/21, LPA Linda M Almaraz conducted a complaint investigation at this facility regarding the same allegation (Illegal eviction), involving the same resident, Resident #1 (R1). During the course of the investigation, LPA Almaraz discovered that the facility had served R1 a 30 day eviction notice for refusing medication and verbally abusing staff. The 30 day eviction notice was served to R1 on 5/13/21. The eviction notice stated the resident had yelled at staff several times from 7/2020 though 5/2021 and had been calling staff "incompetent, liar and lazy" while expressing dissatisfaction with their care. During file review, it was

Unsubstantiated

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: 07/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

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-20210514091631

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: 07/07/2021

NARRATIVE

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discovered that R1's Appraisal/Needs and Service Plan had not been updated since the initial one conducted on 7/9/2020, to reflect the R1's non-compliance with medication. Based on the investigation conducted by LPA Almaraz, there was no evidence found to support that R1 had been verbally abusive by yelling at staff and R1 has the right to refuse medication. The allegation of Illegal Eviction was Substantiated by LPA Almaraz on 6/2/21 and deficiencies were issued under California Code of Regulations Title 22.
Please refer to Complaint #28-AS-20210526164252, dated: 5/26/21 for additional information.

This concludes the investigation on "Illegal eviction" based on the findings delivered by LPA Almaraz.
An exit interview was conducted and a copy of this report was provided to the Assistant Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

LIC9099 (FAS) - (06/04)

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