198603286-3-8-2022-28-AS-SCOL-CFNV55-20220623160722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/08/2022
Date Signed: 03/08/2022 11:52:54 AM

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
02/17/2022 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20220217154432

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: 50	DATE:	03/08/2022
		UNANNOUNCED	TIME BEGAN:	10:48 AM
MET WITH:	Alex Solorio. Assistant Administrator		TIME COMPLETED:	11:56 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Illigal Eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced subsequent complaint investigation visit to facility and was greeted by Assistant Administrator Alex Solorio. Initial visit was conducted on 02/23/22

The investigation consisted of asking for and obtaining copies of resident rooster, staff roster, Appraisal needs for R1, and services plan dated 02/10/2022 for R1. Copy of 30-day eviction notice, copy of proof of service, SSI Notice of Change in Payment, Admission Agreement, copies of invoices from 09/01/2021 to 02/02/2021, SIR dated 11/24/2021, SOC 341 dated 12/09/2021.
LPA Interviewed Assistance Administrator Alex Solorio, Business office staff Kevin Arutyunyan and R1. LPA interview case worker from Brilliant corners Trinidad Martinez and he stated he was aware of resident and has contingency plan if resident needs to leave.

R1 admitted that RI has not paid to due to being robbed (no police report filed) and dental expenses. RI stated mother has mailed a check for balance due to facility on 2/23/2022. (continued on 9909C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

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 2

Control Number 28-AS-20220217154432

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: 03/08/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Continued from 9099)
R1 stated she applied for rental relief on 02/11/22. Facility has followed proper procedures to evict resident.

During this subsequent visit, Administrator stated that they received personal check dated 2/22/2022 for amount of $3,317.85 from resident’s mother which brings resident up to date on her back rent. Facility stated that resident paid rent for March 2022 and is up to date.

NOTE: Due to resident paying her back rent and current month, LPA asked facility to rescind eviction notice and copy of that notice was obtained by LPA.

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. A copy of this report and appeal rights were left with the Administrator Alex Solorio whose signature on this form confirm receipt of this document.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2