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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:16:19 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
10/05/2020 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201005141056
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: 59DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Alexander Solorio - Assistant AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not assist residents with medications as needed.
Centrally stored medications are not kept in a safe and locked place.
Unqualified staff administer injections to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit.

The investigation consisted of the following: LPA obtained a copy of the residents and staff rosters, conducted a tour, and interviewed the Administrator, Med-tech 1 (M1), Med-tech 2 (M2), and Resident 1 – Resident 7 (R1-R7).

The investigation revealed the following: regarding the allegation "staff did not assist residents with medications", it is alleged that the facility's licensed vocational nurse (LVN) ignores residents who are sufferring and in needs of medications. Example of medications include pain and nausea medications. No specific names of residents were provided.
(CONTINUED TO LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
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-20201005141056
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: 08/04/2022
NARRATIVE
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Interviews conducted with assistant administrator and med-techs revealed that medications are given in a timely manner and the med-techs administer medications at 8am, 12pm, 5pm, and 8pm. The med-techs do not refuse to give medication to residents. However, there are times when it is not time to give the second dose and they advise the residents to wait. The med-techs strictly follow the doctor's orders to avoid overdosing the residents. Medications like narcotics can't be given constantly and need be to given hours apart per doctor's orders. Interviews conducted with residents revealed that they receive their medication on time and med-techs do not refuse to give them their medications.

The investigation revealed the following: regarding the allegation "centrally stored medications are not kept in a safe and locked place.", it is alleged that the facility's LVN leaves bags of medications on the floor in her office. Interviews conducted with assistant administrator and med-techs revealed that the LVN, who no longer works here, would organize the new medications and place the old medications on the floor in her office to discard. The medication was never left unattended and when the LVN stepped out of the office she would locked the door. Once she was done organizing then she would store and lock the new medication and properly discard the old medication. No resident had access to her office. Interview conducted with residents revealed that they have not observed medication unattended and that they keep it safe and locked in the medication room.

The investigation revealed the following: regarding the allegation "unqualified staff administer injections to residents.", it is alleged that the facility's LVN instructed med-techs who are not qualified to administer injections to inject residents. Interviews conducted with assistant administrator and med-techs revealed that during the time that the LVN worked at this facility there was no residents that required injections. There were only residents that self-administer insulin pens. However, the med-techs do not directly administer the insulin pen on the residents. They provide the insulin pen to the resident and the resident injects themselves while the med-tech observes them and assist once they are done. Currently the facility has only one resident that requires a behavioral injection. Interview with this resident revealed that a doctor or licensed nurse comes to the facility to inject him.



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.

Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2