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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:22:05 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
03/08/2021 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210308152714
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: 61DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Asst. Administrator, Alexander SolorioTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
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9
Financial abuse.

Facility staff failed to report incidents to agencies.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #2 (S2: Receptionist/Activities Director, Maddison Aceves). LPA/RA spoke to S2 prior to entering the facility to conduct a risk assessment. S2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA/RA Ceniceros later met with Asst. Administrator (A2: Alexander Solorio); as Administrator (A1: Kandice Vergara) was unavailable.

The purpose of today's visit is to conduct a subsequent visit and to deliver the findings pertaining to the above-mentioned allegations. The initial 10-Day virtual visit was conducted by LPA Joe Katrdzhyan on 03/16/21 (via telephone) with Administrator (A1: Kandice Vergara) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed (between 8:30 a.m. - 10:00 a.m.) Asst. Administrator, Business Office
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
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 3
Control Number 28-AS-20210308152714
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: 08/18/2022
NARRATIVE
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Manager (S1: Kevin Arutyunyan), Staff #2, and Resident #3. LPA/RA did not interview Resident #1 who moved on 09/16/21, Resident #2 moved on 04/24/21, and Resident #4 moved on 10/25/21. LPA/RA Ceniceros reviewed (between 10:00 a.m. - 10:45 a.m.) pertinent documents: Admissions Agreement, Emergency I.D. & Information; Record of Resident's Safeguarded Cash Resources, Billing Statements, and March 2021 Invoices for Residents #1, #2, #3, #4.

Regarding Allegation #1: this investigation revealed that Residents #1, #2, #3, and #4 were a participants of the Pacific PACE Program. Facility would bill Pacific Pace $60 per day for Residents #1, #3, #4 and $33 per day for Resident #2. Pacific PACE would pay a portion of the residents' rent and the residents would pay the remaining balance. (LPA/RA reviewed Resident #1, #2, #3, and #4 Admission Agreement for the rent amount and March 2021 Invoices that documented Resident #1, #2, #3, and #4 "outstanding" balances.) Interviews conducted with facility staff corroborated that Pacific PACE pays for the level of care for Resident #1, #2, #3, and #4; and, the residents pay for their room and board from the money they receive from SSI. In an attempt to change the payee to the facility, Residents #1 #2, #3, and #4 refused to do so. Pacific PACE was being billed each month; however, the facility had been receiving late payments from Pacific PACE and no payments from Residents #1, #2, #3, and #4 which accumulated to an "outstanding" balance. The facility was willing to take a loss from not collecting the "outstanding" balances from Residents #1, #2, #3, and #4 as an agreement that the facility become the payee for Residents #1, #2, #3, and #4. Resident #1's personal funds were going elsewhere (family), but never paid the rent. Resident #2 had own card with funds and spent money on personal items, but nothing towards the rent. Resident #3 had own card with funds and spent majority of money on personal items, but nothing towards the rent. Resident #4 had own own card with funds and spent the money on personal items, but nothing towards the rent. (LPA/RA reviewed Invoice #0324B (dated 03/01/21) documented Resident #1 owed $6,701.42; Invoice #0320B (dated 03/01/21) documented Resident #2 owed $6,523.17; Invoice #0321B (dated 03/01/21) documented Resident #3 owed $5,701.42; Invoice #0329B (dated 03/01/21) documented Resident #4 owed $5,450.35).

Based on the evidence gathered and interviews conducted and records reviewed, LPA/RA Ceniceros did not observe financial abuse from the facility to Residents #1, #2, #3, and #4. 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 of FINANCIAL ABUSE: Financial Abuse is found to be UNSUBSTANTIATED.

SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210308152714
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: 08/18/2022
NARRATIVE
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3
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Regarding Allegation #2: this investigation revealed that Residents #1, #2, #3, and #4 are participants of the Pacific PACE Program who pays for the level of care for Residents #1, #2, #3, and #4. Pacific PACE Program began; however, Residents #1, #2, #3, and #4 did not have an assigned social worker; therefore, facility staff would make notifications regarding these residents thru a direct line to Pacific PACE and left a message and followed up with an e-mail regarding the incident. (LPA/RA Ceniceros reviewed e-mails (dated 03/01/21, 03/08/21, and 03/24/21 from (former) Staff #3 (S3: Business Office Manager, Gretel De San Diego) to the agency regarding Residents #1, #2, #3, and #4 "outstanding" balances, effective 03/01/21. (LPA/RA reviewed Invoice #0324B (dated 03/01/21) documented Resident #1 owed $6,701.42; Invoice #0320B (dated 03/01/21) documented Resident #2 owed $6,523.17; Invoice #0321B (dated 03/01/21) documented Resident #3 owed $5,701.42; Invoice #0329B (dated 03/01/21) documented Resident #4 owed $5,450.35).

Based on the evidence gathered and interviews conducted and records reviewed, LPA/RA Ceniceros observed documentation of communication (via e-mail) between the facility and agency. 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 of REPORTING REQUIREMENTS: Facility staff failed to report incidents to agencies is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Asst. Administrator, Alexander Solorio.

SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3