198603286-4-7-2022-28-AS-MVAO-CEKU8N-20220519152149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:18:33 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
02/03/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220203121715

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:	01:30 PM
MET WITH:	Assistant Administrator / Alexander Solorio		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Lack of supervision resulting in a physical altercation between residents.

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 "Lack of supervision resulting in a physical altercation between residents". Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit.

LPA Katrdzhyan conducted prior visits to this facility on 2/11/22 and 3/11/22, in reference to the allegation listed above. The investigation consisted of interviews of various persons to include the Assistant Administrator / Alexander Solorio, Staff members 1 and 2 (S1 and S2) and Residents 1 and 2 (R1 and R2). Also, copies of the following documents were obtained and reviewed in reference to R1 and R2;

• Client Face Sheet • Appraisal/Needs and Services Plan • Physician's Report • Unusual Incident/Injury Report / LIC 624.
(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: 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-20220203121715

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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The investigation revealed the following;

Allegation: Lack of supervision resulting in a physical altercation between residents.
According to the Unusual Incident/Injury Report submitted by the facility, on 2/1/22, at approximately 6:45pm, R1 and R2 were both in their room when an altercation occurred. R1 had initiated a conversation with R2 at which time R2 yelled at R1 stating "I don't like talking" and proceeded to physically attack R1.
Based on record reviews and interviews conducted, LPA learned that on 2/1/22, R1 was moved into the same room as R2, due to both residents testing positive for COVID. Prior to the move, both residents were informed about temporarily rooming together and presented no concerns. The incident involving R1 and R2 happened shortly after on 2/1/22, while both residents were quarantining together in the red zone. Residents and Staff interviewed confirmed that staff were not present during the incident but upon hearing the commotion, immediately assisted in breaking up the altercation and separating both residents. R1 sustained a few scratches to his face and a swollen lip but refused medical attention. Staff assisted R1 by applying fist aid. Per the Assistant Administrator, there have been no prior incidents involving R1 and R2 and both residents are independent and do not require one to one supervision. This was an isolated incident.
According to the Appraisal/Needs and Services Plan for R1, R1 is listed as emotionally stable and usually keeps to himself. According to the Appraisal/Needs and Services Plan for R2, R2 is listed as emotionally stable and likes to socialize with other residents. Residents and Staff interviewed confirmed that staff could not have done anything different to prevent the incident from happening. All reporting parties were notified of the incident, including the Pasadena Police Department. The Pasadena Police Department was involved and came out and spoke with both residents. R1 refused to press charges against R2.

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.

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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