198603286-2-1-2022-28-AS-MVAO-CEKR9F-20220519124928

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 02/01/2022
Date Signed: 02/01/2022 03:32:19 PM

Unsubstantiated

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
01/24/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220124153310

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: 60	DATE:	02/01/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Assistant Administrator / Alexander Solorio		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff restrained resident to a bed.

Staff are threatening resident’s life.

Staff are attempting to steal resident’s money.

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 Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegations of "Staff restrained resident to a bed, Staff are threatening resident’s life and Staff are attempting to steal resident’s money".

During today's visit, LPA interviewed the Assistant Administrator, Resident #2 (R2) and Staff #1 (S1). LPA was unable to interview Resident #1 (R1) as R1 expired on 1/28/22. Also, copies of the following documents were obtained and reviewed in reference to R1;

• Resident Face Sheet • Appraisal/Needs and Services Plan • Physician's Report • Unusual Incident/Injury Report / LIC 624 • Hospice Records
(Please see LIC 9099C for additional information)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022

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-20220124153310

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: 02/01/2022

NARRATIVE

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The investigation revealed the following;

Allegations: Staff restrained resident to a bed, Staff are threatening resident’s life and Staff are attempting to steal resident’s money. Based on interviews conducted and records reviewed, LPA discovered that R1's health began deteriorating around the end of December 2021 and beginning of January 2022. R1 had been receiving hospice services since 4/2/21. During R1's stay at Pasadena Villa Senior Living, R1 shared a room with R2 until 1/6/22. Staff began noticing the rapid deterioration in R1's mental state and moved R1 to a private room on 1/6/22. R1 was often observed by staff and his roommate to be disoriented and paranoid. Per statements obtained, R1 would hallucinate and accuse staff (no staff in particular) of strapping him down to his bed, trying to kill him and stealing his money. R1 also accused R2 of trying to kill him and stealing his money. On 12/12/21, Officers Woolford and Goretti, from the Pasadena Police Department responded to Pasadena Villa Senior Living in regards to a call made by R1, stating that "Staff is trying to 187 him". Upon arriving at the facility, the Officers contacted R1 who stated that yesterday morning, a male staff member strapped him down to his bed, they were trying to kill him and take his social security income by throwing him in a river in Long Beach. R1 stated that he was still strapped down to the bed. The Officers inspected R1's bed in person and observed that R1 was not strapped down to his bed and there was no obvious sign of injury. The Officers found no crime had occurred and ended their visit. On 1/28/22, R1 expired while receiving hospice services through Comfort Choice Hospice. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations of "Staff restrained resident to a bed, Staff are threatening resident’s life and Staff are attempting to steal resident’s money".

Although the allegations 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 allegations are Unsubstantiated.

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

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022

LIC9099 (FAS) - (06/04)

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