198603286-5-20-2022-28-AS-SCOL-CEXQGE-20220531120923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 05/20/2022
Date Signed: 05/20/2022 10:14:30 AM

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
03/02/2021 and conducted by Evaluator Luis Mora

COMPLAINT CONTROL NUMBER: 28-AS-20210302110357

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: 53	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff not responding to resident's call light.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted a subsequent unannounced complaint visit regarding the above allegation. LPA met with Alexander Solorio and explained the reason for the visit.

The investigation consisted of the following: On 03/11/2021, LPA Joe Katrdzhyan conducted an initial complaint investigation via telephone due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). On 10/20/2021, LPA Luis Mora conducted a subsequent complaint visit and obtained copies of staff & resident rosters, call light & response time in-service training. LPA also interviewed Resident 1 - Resident 7 (R1-R7), Administrator, and Staff 1 - 5 (S1-S5), and toured facility. On today’s visit 05/20/2022, LPA Luis Mora delivered findings.

The investigation revealed the following: regarding the allegation “staff not responding to resident's call light” it is alleged that caregivers are not instructed to attend to the pendant or call light especially on the 10:30pm to 6:30 am shift. (CONTINUED TO LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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-20210302110357

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: 05/20/2022

NARRATIVE

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The investigation revealed the following: regarding the allegation “staff not responding to resident's call light” it is alleged that caregivers are not instructed to attend to the pendant or call light especially on the 10:30pm to 6:30 am shift.

Interviews conducted with staff revealed that in early March 2021 there was a caregiver during the graveyard shift that was caught on camera sleeping or on their phone and not responding to the call light. A call light system & response time in-service training was conducted on 03/11/2021. The facility reduced the caregiver’s hours due to continued poor work performance; this resulted in the caregiver resigning on 05/05/2021.

Interviews conducted with residents revealed that the staff are responding quickly to their call light and there is no longer an issue with the response time. During the tour the LPA pressed the call light in 3 random resident rooms and the response time was between 2-4 minutes.

Based on LPA's interviews which were conducted, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210302110357

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: 05/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/27/2022 Section Cited CCR 87415(a)(2)	1 2 3 4 5 6 7	87415(a)(2) - Night Supervision (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m....shall be available... to assist in caring for residents. (2)In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake....	1 2 3 4 5 6 7	Licensee will conduct an in-service training in rgards to the call light and submit POC to LPA by 05/27/2022. It has been confirmed that an in-service training has already been conducted on 03/11/2021 when this allegation was brought up. POC cleared.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: LPA's interviews with staff revealed that there was a staff not responding to the call light. This poses a potential health and safety risk to residents in care	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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

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