198603286-12-22-2021-28-AS-MVAO-CC5UCJ-20220302142800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 12/22/2021
Date Signed: 12/22/2021 11:41:34 AM

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
12/14/2021 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211214122415

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: 47	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Alexander Solorio		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Resident is being financially abused while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint investigation toward the above allegation. LPA met with Assistant Administrator Alexander Solorio and explained the reason of the visit and he also assisted LPA with the visit.

The investigation consisted of the following: LPA interviewed five residents (R1-R5), assistant administrator and three staff (S1-S3) and obtained copy of resident roster, Resident#1 (R1) face sheet, preplacement appraisal information and case assessment/evaluation and contact information for Pasadena Police Department.

The investigation revelaled of the following: Allegation "Resident is being financially abused while in care." LPA interviewed Resident#1 (R1) and stated that the debit card was missing and got stolen in the facility.
(See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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-20211214122415

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: 12/22/2021

NARRATIVE

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R1 also stated that approximately $2000 was withdrawn by someone, and due to the pin number was on the back of the card and the bank was not able to reimburse the money back to R1. LPA asked R1 for the copy of the bank statement and R1 said no access on it and no record for the bank statement. In addition, R1 does not remember what date the money was withdrawn which before or after the hotel trip with family. LPA interviewed residents and staff and both denied seeing any suspicious people went into R1's room or around the hallway. The residents all felt safe living in the facility and they never lost or got stolen for any costly items in the facility. The staff also reported R1's room is always locked. Administrator also stated that the police officer came but they were not able to open up the case for R1 due to R1 was not able to provide the details of bank statement and the inconsistent statement for R1. The police officer will open up the case when R1 is willing to provide the statement but till now, R1 still has not provided any bank statement to the police officer. Based on LPA's interviews conducted and record review, the incident of resident is being financially abused while in care, there is insufficient 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 allegation is UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report and appeal right was provided to the Assistant Administrator.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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