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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/11/2022
Date Signed: 03/11/2022 01:55:07 PM

Substantiated


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
03/09/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220309172035
FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 48DATE:
03/11/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff / Rocio Rosas
Assistant Administrator / Alexander Solorio		TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident eloped from facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Rocio Rosas and was later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Resident eloped from facility".

During today's visit, LPA interviewed the Assistant Administrator / Alexander Solorio and Responsible Party / Family Member of Resident #1 (R1). LPA was unable to interview R1 as R1 does not reside at this facility and is staying with family. Also, copies of the following documents were obtained and reviewed in reference to R1;
• Client Face Sheet • Preplacement Appraisal Information • Resident Appraisal • Physician's Report
• Functional Capability Assessment • Unusual Incident/Injury Report / LIC 624 • Medication Release Form
• Consent for Emergency Medical Treatment • Admission Agreement • Discharge Instructions from LAC+USC
• R1's Exit Form from facility • Resident Roster Sheet.
(Please see LIC 9099C for additional information)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20220309172035
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: 03/11/2022
NARRATIVE
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The investigation revealed the following;

Allegation: Resident eloped from facility.
Based on interviews conducted and record reviews, LPA discovered that R1 was discharged from LAC-USC on 3/7/22 and transferred to Pasadena Villa Senior Living (PVSL). R1 was admitted to PVSL on 3/7/22, at approximately 2:45pm (Note: R1 was not a resident of PVSL prior to 3/7/22). Shortly after being admitted to PVSL, R1 is observed (in surveillance video at 4:17pm) leaving the facility through the front door without staff supervision. Facility staff did not witness R1 leaving the facility and it wasn't until later, while conducting room checks when staff discovered R1 had eloped. A missing person's report was filed with the Pasadena Police Department on the evening of 3/8/22 and R1 was found by Officers a few blocks away from the facility on the morning of 3/9/22, at approximately 9:30am. R1 has not returned to PVSL and is currently staying with family. Per the physician's report dated 3/1/22, R1 is not able to leave the facility unassisted. R1 eloping from the facility poses an immediate health and safety risk to R1.

Based on LPA’s observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220309172035
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: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2022
Section Cited
CCR
87101(c)(3)
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Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents.
The requirement is not met as evidenced by;
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Licensee will submit a plan to CCL ensuring the safety measures the facility will implement (effective 3/11/22) to ensure residents who are listed as not able to leave the facility unassisted, do not elope from the facility. The plan must not violate the personal rights of residents. POC is due to CCL by 3/12/22.
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On 3/7/22, R1 is observed (in surveillance video at 4:17pm) leaving the facility through the front door without staff supervision. Facility staff did not witness R1 leaving the facility and it wasn't until later, while conducting room checks when staff discovered R1 had eloped. Per the physician's report dated 3/1/22, R1 is not able to leave the facility unassisted. This poses an immediate health and safety risk to R1.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/09/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220309172035

FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 48DATE:
03/11/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff / Rocio Rosas
Assistant Administrator / Alexander Solorio		TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
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8
9
Facility did not report resident missing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Rocio Rosas and was later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Facility did not report resident missing".

During today's visit, LPA interviewed the Assistant Administrator / Alexander Solorio and Responsible Party / Family Member of Resident #1 (R1). LPA was unable to interview R1 as R1 does not reside at this facility and is staying with family. Also, copies of the following documents were obtained and reviewed in reference to R1;
• Client Face Sheet • Preplacement Appraisal Information • Resident Appraisal • Physician's Report
• Functional Capability Assessment • Unusual Incident/Injury Report / LIC 624 • Medication Release Form
• Consent for Emergency Medical Treatment • Admission Agreement • Discharge Instructions from LAC+USC
• R1's Exit Form from facility • Resident Roster Sheet.
(Please see LIC 9099C for additional information)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220309172035
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: 03/11/2022
NARRATIVE
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The investigation revealed the following;

Allegation: Facility did not report resident missing.
Based on interviews conducted and record reviews, LPA discovered that R1 was discharged from LAC-USC on 3/7/22 and transferred to Pasadena Villa Senior Living (PVSL). R1 was admitted to PVSL on 3/7/22, at approximately 2:45pm (Note: R1 was not a resident of PVSL prior to 3/7/22). Shortly after being admitted to PVSL, R1 is observed (in surveillance video at 4:17pm) leaving the facility through the front door without staff supervision. Facility staff did not witness R1 leaving the facility and it wasn't until later, while conducting room checks when staff discovered R1 had eloped. On 3/7/22, the Responsible Party / Family Member of R1 was notified by the Assistant Administrator that R1 had eloped from the facility. There was a discussion between the Responsible Party / Family Member and the Assistant Administrator that only one person would need to file the missing person’s report and the Responsible Party / Family Member stated that she would be filing the missing person’s report for R1. A missing person's report was filed with the Pasadena Police Department on the evening of 3/8/22 and R1 was found by Officers a few blocks away from the facility on the morning of 3/9/22, at approximately 9:30am. R1 has not returned to PVSL and is currently staying with family. Based on interviews conducted, LPA learned that there was an understanding between Facility Staff and the Responsible Party / Family Member of R1 on who would be filing the missing person's report to Law Enforcement therefore facility is not in violation for not reporting R1 missing to Law Enforcement.

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 was provided to the Assistant Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5