198603286-10-20-2021-28-AS-MVAO-CCDSM6-20220310125924

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 10/20/2021
Date Signed: 10/20/2021 03:49:16 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
04/07/2021 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210407154550

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:	10/20/2021
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff not administering medication in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit regarding the above allegation. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit.

The investigation consisted of the following: On 04/14/21, LPA Joe Katrdzhyan conducted an initial complaint investigation via telephone due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). Today's visit: LPA Luis Mora obtained copies of staff & client rosters, call light & response time in-service training signing in sheet, and medication records for Resident #1 - Resident #7 (R1-R7). LPA also interviewed Resident #1 - Resident #7 (R1-R7) and Staff #1 - #5 (S1-S5), and toured facility.

The investigation revealed the following: it's alleged that staff are not administering the medication in a timely manner. Based on interviews conducted with residents, 7 out of 7 stated that they get their medication on time and have had no issues receiving their medication.
(CONTINUED TO LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

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-20210407154550

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: 10/20/2021

NARRATIVE

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Based on interviews conducted with staff, 2 out of 5 stated that they have a schedule to administer the medication and they follow that schedule timely. The other 3 staff interviewed do not administer medication. LPA also reviewed medication records for R1 - R7 and observed proper documentation. Therefore, there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with residents and staff, and review of medication records, there was not enough supportive 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 violations did or did not occur, therefore the allegation are UNSUBSTANTIATED.

Exit interview was held with Assistant Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

LIC9099 (FAS) - (06/04)

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