198603286-8-18-2022-28-AS-MVAO-CJ8NW6-20220913104859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:31:51 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
04/22/2021 and conducted by Evaluator Elizabeth Ceniceros

COMPLAINT CONTROL NUMBER: 28-AS-20210422132803

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: 61	DATE:	08/18/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Asst. Administrator, Alexander Solorio		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not meet the needs of the resident which resulted in hospitalization.

Staff did not take the resident to the doctor.

Staff did not arrange for transportation.

INVESTIGATION FINDINGS:

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

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 04/29/21 (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 12:30 p.m. - 1:15 p.m. Asst. Administrator, Staff #2. LPA/RA did not interview Resident #1 as the resident no longer resides at the facility effective 03/25/21.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (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-20210422132803

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

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

Regarding Allegation #1: this investigation revealed that Asst. Administrator Solorio was unaware of Resident #1 becoming ill health upon moving out of the facility on 03/25/21 that later required a 7-day hospitalization. Resident #1 (R1) was receiving home health care by (American Home Health) twice a week (based on R1's home health agency agreement, dated 11/18/20 thru 03/25/21). The facility also has a House Doctor and Nurse Practitioner who visit the facility once a month or as needed to provide medical care for any change of conditions with the residents. Resident #1 was a participant of the Enriched Residential Care (ERC) housing program and had an assigned Case Manager through the Department of Housing for Health (DHH) and would schedule all the resident's medical, dental, optical, podiatry appointments and then inform facility staff. Witness #1 (W1: Carmen Zavala, DHH Case Manager) confirmed that Resident #1's needs were being met by facility staff; however, Resident #1 was inpatient and very demanding.

Based on the evidence gathered and interviews conducted and records reviewed, 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 NEGLECT/LACK OF SUPERVISION: Staff did not meet the needs of the resident which resulted in hospitalization is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that Resident #1 had an involved Case Manager through the Department of Housing for Health (DHH). Asst. Administrator Solorio stated that the facility staff together with Resident #1's DHH Case Manager were doing everything with doctors appointments through virtual visits or FaceTime; and, appointments that could be moved to the following month (i.e., optometrist, dental, optical, podiatry) were being re-scheduled due to the COVID-19 pandemic. Resident #1 (R1) was receiving home health care twice a week and attended all appointments. (LPA/RA Ceniceros observed doctors' appointments for Physician on 08/20/20, Dental on 01/14/21 and 03/04/21, Internal Medicine on 03/22/21, and e-mails, dated 11/05/20 and 04/22/21.) Witness #1 (W1: Carmen Zavala, DHH Case Manager) confirmed that Resident #1 would attend all scheduled doctors' appointments.

Based on the evidence gathered and interviews conducted and records reviewed, 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 NEGLECT/LACK OF CARE: Staff did not take the resident to the doctor is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed that the facility (together with Resident #1's DHH Case Manager) worked together to get Resident #1 transportation services through Access, effective 01/11/21.

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (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-20210422132803

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

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

Asst. Administrator Solorio stated that R1 would refuse to be transported to appointments and requested for the DHH Case Manager to accompany the resident. Witness #1 (W1: Carmen Zavala, DHH Case Manager) confirmed that she would communicate to facility staff whenever the agency (ERC) scheduled Resident #1's medical/dental/optical/podiatry appointments; so transportation was provided to Resident #1. (LPA/RA reviewed R1's documentation: dental appt. on 03/04/21; LAC+USC Medical Center ED visit on 04/25/20). Witness #1 (W1: DHH Case Manager, Carmen Zavala) confirmed that Resident #1 at times did not want to travel to doctors' appointment; therefore, W1 would accompany the resident from time to time. (LPA/RA Ceniceros reviewed e-mails (dated 08/20/20, 11/05/20, 02/26/21, 03/18/21) between facility staff and DHH Case Manager in regards to scheduling Resident #1's transportation to and from appointments. Facility staff would escort Resident #1 to the physician's and dental appointments located around the corner from the facility; therefore, no transportation would be needed at that time.

Based on the evidence gathered and interviews conducted and records reviewed, 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 PERSONAL RIGHTS: Staff did not arrange for transportation 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 Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (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