198603286-4-7-2022-28-AS-MVAO-CEKTGR-20220519144334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:17:04 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
01/04/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220104100438

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: 48	DATE:	04/07/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Assistant Administrator / Alexander Solorio		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff failed to prevent resident from AWOL’ing from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Staff failed to prevent resident from AWOL’ing from facility.". Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 1/6/22, in reference to the allegation listed above. The investigation consisted of interviews of various persons to include the Assistant Administrator, Staff members 1 - 3 (S1 - S3) and Resident 2 (R2). LPA made multiple attempts to interview Resident 1 (R1) but was unsuccessful as calls were not returned and R1 no longer resides at this facility.
During today's visit, LPA learned that R1 was hospitalized on 1/16/22, at Riverside Community Hospital and remains hospitalized. Per the Assistant Administrator, R1 will not be returning back to the facility. Copies of the following documents were obtained and reviewed in reference to R1;
• Client Face Sheet • Appraisal/Needs and Services Plan • Physician's Report • Unusual Incident/Injury

Substantiated

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: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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-20220104100438

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: 04/07/2022

NARRATIVE

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Report / LIC 624.

The investigation revealed the following:

Allegation: Staff failed to prevent resident from AWOL’ing from facility.
Based on interviews conducted and record reviews, LPA learned that on 1/1/22, at approximately 8am, R1 eloped from the facility in her wheelchair. According to the Ring doorbell footage of the front door, R1 was last observed smoking outside (near the main entrance door), as she sat in her wheelchair. At the time of the incident, there were 2 caregivers and 1 med tech working at the facility and all were busy assisting residents and did not observe R1 leaving the facility. From the interviews conducted, LPA learned that on the weekends, the front desk staff does not begin their work shift until 9am and there is no staff monitoring the front desk area and resident traffic going in and out of the facility between the hours of 6:30am and 9am. Although the facility is equipped with a surveillance system, the facility needs to have staff supervision in the early hours to ensure residents are not leaving the facility without informing staff and/or without assistance. Per R1's Physician's Report, R1 is not able to leave the facility unassisted. This poses an immediate health and safety risk to R1. All reporting parties were notified of the incident, including the Pasadena Police Department.

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220104100438

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: 04/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/08/2022 Section Cited CCR 87101(c)(3)	1 2 3 4 5 6 7	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;	1 2 3 4 5 6 7	Licensee will submit a plan to CCL ensuring the safety measures the facility will implement ensuring residents are not leaving the facility without informing staff and/or without assistance. POC is due to CCL by 4/8/22.
	8 9 10 11 12 13 14	On 1/1/22, at approximately 8am, R1 eloped from the facility in her wheelchair. From the interviews conducted, LPA learned that on the weekends, the front desk staff does not begin their work shift until 9am and there is no staff monitoring the front desk area and resident traffic going in and out of the facility between the hours of 6:30am and 9am. Per R1's Physician's Report, R1 is not able to leave the facility unassisted. This poses an immediate health and safety risk to R1.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC9099 (FAS) - (06/04)

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