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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 05/18/2022
Date Signed: 05/18/2022 04:30:27 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
05/11/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220511161940
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: 53DATE:
05/18/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident is smoking around an oxygen tank

Facility doesn't have enough towels for residents
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 "Resident is smoking around an oxygen tank and Facility doesn't have enough towels for residents".

During today's visit, LPA interviewed the Assistant Administrator / Alexander Solorio, Staff members 1 and 2 (S1 and S2) and Residents 1 through 5 (R1 - R5). LPA toured the facility and inspected the linen closets and laundry room. Also, a copy of the Behavior Contract for R1 was reviewed and obtained.


(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: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
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-20220511161940
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: 05/18/2022
NARRATIVE
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The investigation revealed the following;

Allegation: Resident is smoking around an oxygen tank. The details of this allegation states that R1 lights up cigarettes and smokes inside her room. R1 uses an oxygen tank and should not be lighting up or smoking cigarettes inside her room.
Based on interviews conducted, LPA learned that Residents 1 and 2 require the use of oxygen administration and are able to administer oxygen on their own. On multiple occasions, R1 was observed by multiple staff and residents lighting up cigarettes inside her room, while oxygen is in use. This poses an immediate health, safety or personal rights risk to persons in care as smoking is prohibited where oxygen is in use. The Assistant Administrator has become aware of this concern and has developed a Behavior Contract with R1 stating that R1 will follow the house rules of Pasadena Villa, R1 will smoke in the designated smoking area and request assistance from staff to be escorted to the smoking area. Failure to follow the Behavior Contract will result in loss of permanent housing and eviction for R1. R1 has agreed and signed the Behavior Contract dated 5/9/22. According to the Assistant Administrator, R1 has been following the Behavior Contract as of 5/9/22 and is no longer non-compliant. Based on interviews conducted and record review, there is sufficient evidence to support this allegation to be true.

Allegation: Facility doesn't have enough towels for residents.
Based on majority of the interviews conducted the statements obtained were consistent and corroborated with the allegation. At 11:35am, LPA toured the facility and inspected the linen closets and laundry room and observed a low supply of bath towels for 53 residents. From interviews conducted, LPA learned that some residents are left without bath towels while their dirty towels are in laundry and some residents have to use a bath robe or a blanket to dry themselves after a bath as the facility does not have an extra supply of bath towels. Based on interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true.

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are 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 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: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220511161940
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: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2022
Section Cited
CCR
87618(b)(3)(C)
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Oxygen Administration - Gas and Liquid. Smoking shall be prohibited where oxygen is in use.
This requirement is not being met as evidenced by:
Residents 1 and 2 require the use of oxygen administration and are able to administer oxygen on their own. On multiple occassions,
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The Assistant Administrator has developed a Behavior Contract with R1 stating that R1 will follow the house rules of Pasadena Villa, R1 will smoke in the designated smoking area and request assistance from staff to be escorted to the smoking area.
According to the Assistant Administrator, R1 has been following the Behavior Contract as of
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R1 was observed by multiple staff and residents lighting up cigarettes inside her room, while oxygen is in use. This poses an immediate health, safety or personal rights risk to persons in care.
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5/9/22 and is no longer non-compliant.

***Citation was cleared at the time of visit and no further action is needed***
Type B
05/18/2022
Section Cited
CCR
87307(a)(3)(C)
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Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident... Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths.
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The Assistant Administrator purchased extra bath towels during the time of this visit and provided a copy of the receipt to the LPA.

***Citation was cleared at the time of visit and no further action is needed***
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The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times...
Based on majority of the interviews conducted the statements obtained were consistent and corroborated with the allegation. At 11:35am, LPA toured the facility and inspected the linen closets and laundry room and observed a low supply of bath towels for 53 residents.
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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: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
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
05/11/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220511161940

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: 53DATE:
05/18/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not meeting resident's laundry needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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10
11
12
13
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 allegation of "Staff are not meeting resident's laundry needs".

During today's visit, LPA interviewed the Assistant Administrator / Alexander Solorio, Staff members 1 and 2 (S1 and S2) and Residents 1 through 5 (R1 - R5). Also, a copy of the Laundry Schedule was reviewed and obtained.

The investigation revealed the following;
Allegation: Staff are not meeting resident's laundry needs. The details of this allegations states that laundry is not being done and a resident has three weeks worth of laundry that needs to be done.
(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: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
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-20220511161940
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: 05/18/2022
NARRATIVE
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Based on interviews conducted the statements obtained were inconsistent and did not corroborate with the allegation. Clients and Staff interviewed confirmed that there is no concern with laundry not being done. Laundry is done regularly, which is once a week or as needed. Based on the information gathered, there is insufficient evidence to support the allegation to be true.

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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5