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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 04/21/2021
Date Signed: 04/25/2021 03:31:45 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
03/24/2021 and conducted by Evaluator Linda M Almaraz
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210324080011
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: 37DATE:
04/21/2021
UNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Assistant Administrator, Alexander SolorioTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff member intimidated resident.
Facility is not following universal precautions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Linda Almaraz initiated a subsequent complaint investigation visit for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this visit was conducted telephonically with Alexander Solorio, Assistant Administrator.

The investigation consisted of the following: On 3/30/21, LPA interviewed Solorio and Staff #1-3.
LPA also requested copies of staff and resident roster, PPE/Universal Precautions in-service training logs for the months of 12/2020-3/2021, PPE invoices, and shower/diaper logs for incontinent residents for the months of 12/2020-3/2021. On 4/21/21, LPA interviewed Residents #1-7 and attempted to interviewed Resident #8 but the resident was at a medical appointment. LPA was informed they did not have logs for incontinent care residents before and have recently implemented a log sometime in March.

(Continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
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-20210324080011
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: 04/21/2021
NARRATIVE
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The investigation revealed the following: Regarding allegation "Staff member intimidated resident," based on interviews conducted with staff and residents no one has been intimidated or treated in rough manner. During interviews with staff they all stated they have not seen or heard any resident be treated rough or be intimated by any other staff member. Staff interviewed also stated they have not been told by any resident that they are or were being intimidated. All residents stated they have never been intimidated.


Regarding allegation "Facility is not following universal precautions," it was alleged that staff was reusing gloves and not changing gloves between residents or after changing a residents diaper. Based on records reviewed and interviews conducted the facility conducts monthly in-service training regarding universal precautions, PPE usage, and Infection prevention. Records also revealed the facility orders PPE on a monthly basis and they also receive some from other agencies. All interviews revealed that staff changes gloves after each use and have not been limited on gloves or asked to use the same gloves. All residents stated they see staff wearing gloves while changing them and disposing the gloves in the trash after being changed.

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.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted via telephone with the Assistant Administrator and a hardcopy was provided via email for signature. Signatures on hardcopy.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
03/24/2021 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20210324080011

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: DATE:
04/21/2021
UNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Assistant Administrator, Alexander SolorioTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Facility is not providing appropriate incontinence care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Linda Almaraz initiated a subsequent complaint investigation visit for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, this visit was conducted telephonically with Alexander Solorio, Assistant Administrator.

The investigation consisted of the following: On 3/30/21, LPA interviewed Solorio and Staff #1-3.
LPA also requested copies of staff and resident roster, PPE/Universal Precautions in-service training logs for the months of 12/2020-3/2021, PPE invoices, and shower/diaper logs for incontinent residents for the months of 12/2020-3/2021. On 4/21/21, LPA interviewed Residents #1-7 and attempted to interviewed Resident #8 but the resident was at a medical appointment. LPA was informed they did not have logs for incontinent care residents before and have recently implemented a log sometime in March.

(Continued on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210324080011
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: 04/21/2021
NARRATIVE
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The investigation revealed the following: Based on interviews conducted, LPA learned staff are to check on residents every two (2) hours to see if they are in need of incontinent care and provide showers for residents two (2) times a week. All residents stated they do receive their two (2) showers a week. However, four (4) out of seven (7) residents stated they are not changed or checked on during the night shift for a diaper change. Per Solorio, the facility did not have a logging system for showers and diaper changes before but have recently implemented a log sometime in mid March of 2021. The facility was only keeping records of shower refusals by residents.

Based on interviews and information obtained the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 1, Article 11. See LIC 9099D.

A telephonic exit interview was conducted with Assistant Administrator and Appeal Rights were provided. A hard copy of the report was emailed for signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210324080011
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: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2021
Section Cited
CCR
87625(b)(2)
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87625 Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.
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The Administrator will review Title 22 Regulations, Section 87625 on Managed Incontinence and conduct an in-service training with all staff and provide a copy of the sign in sheet of all attendees along with the topics covered during the in-service training. POC is due to CCL by 4/28/21.
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This requirement was not met as evidence by: During interviews conducted with residents it revealed they are not changed often and are not being changed during the night. Per Assistant Administrator, there was no logging system before and have recently implemented a log to monitor the care.
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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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5