198603286-7-6-2022-28-AS-RORN-CJ8V4H-20220913160622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/06/2022
Date Signed: 07/06/2022 03:30:56 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
06/28/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220628090132

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: 55	DATE:	07/06/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Assistant Administrator / Alexander Solorio Executive Director / Kandice Vergara		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Residents engaged in altercation while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio and was later joined by the Executive Director / Kandice Vergara who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Residents engaged in altercation while in care".

During today's visit, LPA interviewed the Executive Director, Assistant Administrator, Staff 1 (S1) and Residents 1 and 2 (R1 and R2). LPA reviewed video surveillance of the incident. Also, a copy of the Unusual Incident/Injury Report was obtained involving R1 and R2.

(Please see LIC 9099C for additional information)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

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-20220628090132

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: 07/06/2022

NARRATIVE

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The investigation revealed the following;

Allegation: Residents engaged in altercation while in care.

On 6/27/22, at approximately 7:38am, there was an incident involving R1 and R2. According to the video surveillance, at 7:37am, R2 is observed exiting his room towards the patio walkway in his wheelchair. A few seconds later, R2 is observed getting up from his wheelchair and walking towards the small gate (near the exit) and closing it. At 7:38am, R1 is observed exiting her room and walking towards R2. (R1 and R2 are in separate rooms but share the same patio) It is unclear in the surveillance video what was said between both residents but a few seconds later, R1 is observed walking towards the wheelchair of R2 and pushing it out of the walkway. R2 is than observed walking towards his wheelchair and it appears as if there were more words exchanged between R1 and R2 and at which time R2 is observed moving his wheelchair towards the wall, standing next to it facing the street. R2 is than observed walking towards the sliding door of R1 and leaning on the wall (with his back towards the wall). Shortly after R2 is observed swinging his left arm towards R1. It is unclear if the swing was an attempt to hit R1 or if it made contact with R1 as R1 was inside the room and not visible in the surveillance video. S1 observed the situation after the incident had occurred and re-directed R2 back to his room.
Interviews conducted of R1 and R2 confirmed that there was no physical altercation between both residents. Both residents denied hitting one another and stated the incident was a verbal argument. It was confirmed that there were no witnesses to the incident. On 6/28/22, R1 was moved to another room by facility staff to ensure both residents stay away from each other and to avoid future incidents. The Pasadena Police Department was involved and conducted interviews of R1 and R2 but no further action was taken.
Based in the information gathered, there is insufficient evidence to support this allegation to be true.

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 and a copy of this report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

LIC9099 (FAS) - (06/04)

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