198603286-6-2-2021-28-AS-CYEE-CDD2VV-20220410174434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 06/02/2021
Date Signed: 06/02/2021 02:17:43 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
05/26/2021 and conducted by Evaluator Linda M Almaraz

COMPLAINT CONTROL NUMBER: 28-AS-20210526164252

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: 36	DATE:	06/02/2021
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Assistant Administrator, Alexander Solorio		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Linda Almaraz and Alberto Lopez conducted a complaint visit to investigate the allegation listed above. LPA's met with Assistant Administrator, Alexander Solorio and discussed the reason for todays visit.

The investigation consisted of the following: LPA's requested and received copies of facility staff and resident roster, Resident #1's file and a copy of the 30 day eviction. LPA's also interviewed Assistant Administrator.

The investigation revealed the following: During interview with Solorio, LPA's learned the facility had served Resident #1 a 30 day eviction for refusing medication and verbally abusing staff. The 30 day eviction notice was given to the resident 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 disatisfaction with their care. (Continued on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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-20210526164252

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: 06/02/2021

NARRATIVE

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During record review, LPA's discovered the residents Appraisal/Needs and Service Plan had not been updated since the initial one conducted on 7/9/2020, to reflect the residents non-compliance with medication.
There is no evidence to support that Resident #1 has been verbally abusive by yelling at staff and the resident has the right to refuse medication.

The State of California, Department of Social Services, Community Care Licensing Division investigated the allegation of illegal eviction, based on records reviewed and interview conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies cited under California Code of Regulations Title 22.

Exit interview was conducted with Solorio and a hard copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210526164252

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: 06/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/10/2021 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	87224 Eviction Procedures (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). (4) If, after admission, it is determined that the resident has a need not previously identified...	1 2 3 4 5 6 7	Administrator shall rescind the 30 day eviction letter and inform the resident immediately in writing the letter has been rescinded and to disregard the notice. The written letter must include "The previously issued eviction notice does not meet the specified legal requirements, is not valid, and has been rescinded, and the noticed deadline for the eviction
	8 9 10 11 12 13 14	and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. The requirement is not met as evidenced by: Upon reviewing the 30 day eviction letter it was determined the resident was not verbally abuse rather yelling at staff and constantly expressing dissatisfaction with their care. The resident also has the right to refuse medication and can't be used a house rule.	8 9 10 11 12 13 14	are invalid." Administrator shall send a copy of the written letter provided to the resident. Administrator will read CCR 87724 and send a written statement confirming he has read and understand the section and will abide by it. Admistrator will send documentation by POC due date to LPA.
Type B 06/11/2021 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:	1 2 3 4 5 6 7	Adminstrator shall conduct re-appraisals for all residents when neeeded and document it. Administrator will update Resident #1's Appraisal/Needs and Services, and send a copy to LPA. Administrator will read CCR 87724 and send a written statement confirming he has read and understand the section and will abide by it.
	8 9 10 11 12 13 14	The requirement is not met as evidenced by: Upon reviewing the residents records it revealed the Appraisal/Needs and Services Plan had not been updated to reflect the residents medication non-compliance or/and change in behavior.	8 9 10 11 12 13 14	Admistrator will send documentation by POC due date to LPA.

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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M Almaraz	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC9099 (FAS) - (06/04)

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