198603286-3-30-2022-28-AS-LHIS-CD6HSW-20220404062750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:20:54 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
03/25/2022 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220325103032

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:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Assistant Administrator, Alex Solorio		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Residents engaged in a physical altercation while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegation. LPA met with Assistant Administrator, Alex Solorio who assisted with today's visit.

Regarding the allegation that residents engaged in a physical altercation while in care, the investigation consisted of Interview(s) with Assistant Administrator, Staff #1, Staff #2, review of facility video surveillance of incident(s) on 3/24/22, review of Resident #1 and Resident #2's files, and Interview(s) with Resident #1 and Resident #2.

The investigation revealed the following: On 3/24/22 Resident #1 and Resident #2 were involved in two separate physical altercation(s). LPA Reviewed video surveillance and observed that in both altercations, staff were present and broke up the altercation(s) right away. Resident(s) and Staff interviewed confirmed that staff who were present, immediately assisted in breaking up the altercation(s). Resident #1 and Resident #2 stated that they were not injured, and did not require medical attention.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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-20220325103032

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: 03/30/2022

NARRATIVE

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Assistant administrator stated that Resident #1 and Resident #2 have had a few previous altercations with each other, and have both been counseled by facility staff in regards to breaking house rules. Assistant Administrator stated that both residents have been issued eviction notices on 3/28/2022. Assistant administrator stated that Resident #1 is moving to another facility today.

Based on LPA's observations and interviews, investigation revealed: Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Admnistrator, Alex Solorio.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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