198603286-9-23-2022-28-AS-RORN-CJNLK5-20220927084859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 09/23/2022
Date Signed: 09/23/2022 11:32:06 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
07/06/2022 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220706122455

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: 58	DATE:	09/23/2022
		UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Alexander Solorio (Assistant Administrator)		TIME COMPLETED:	10:58 AM

ALLEGATION(S):

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Staff do not assist residents with showers.
Staff do not provide residents with housekeeping services.
Facility does not meet resident's dietary needs.
Facility is not providing laundry services to residents on a regular basis.
Staff is not ensuring the facility is free of odor from incontinent residents.

INVESTIGATION FINDINGS:

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***This complaint report LIC9099 supersedes LIC9099 dated 07/13/22.***

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Assistant Administrator Alexander Solorio and explained the purpose of the visit.

During today's investigation, LPA obtained and reviewed a copy of the Staff/Resident rosters, laundry schedule, shower schedule and food menu. LPA toured the facility with Staff #1. Interviewed Residents #1 to #6 in various locations of the facility and interviewed Staff #1 to #6 in the office.

In regards to the allegation: Staff do not assist residents with showers. Interviews with 6 of 6 Residents who need shower assistance indicate that they are receiving shower assistance at least twice a week. Interviews with caregiving staff who provide assistance with shower indicate that showers are provided twice a week and as need. A review of the shower schedule clearly outline Residents in need of shower assistance and on which days of the week services are provided. Continue to LIC9099C.......

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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-20220706122455

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: 09/23/2022

NARRATIVE

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***This complaint report LIC9099C supersedes LIC9099C dated 07/13/22.***

In regards to the allegation: Staff do not provide residents with housekeeping services. Interviews with 6 of 6 Residents indicate Staff is providing housekeeping services daily and full cleaning services on a weekly basis. Interviews with housekeeping Staff indicate they clean the facility and Resident bedrooms on a daily basis.

In regards to the allegation: Facility does not meet resident's dietary needs. LPA observed sufficient food supplies to meet the needs of Residents. Review of the food menu indicate nutritious meals are provided 3 times a day. Interviews with kitchen staff indicate Residents are receiving 3 meals a day based on the posted menu. Kitchen staff is aware of Residents on modified diets and are providing the proper modified meals. Interviews with Resident indicate they are receiving 3 nutritious meals a day and of good portions. Resident mentioned on this complaint regarding a modified diet revealed during an interview that they are not on a modified diet.

In regards to the allegation: Facility is not providing laundry services to residents on a regular basis. Interviews with 6 of 6 Resident indicate that laundry services are provided on a weekly basis. Interviews with Staff indicated laundry services is provided on a weekly basis. Review of the laundry schedule clearly outlines laundry services provided to Residents and on which date it is provided.

In regards to the allegation: Staff is not ensuring the facility is free of odor from incontinent residents. Interviews with Residents indicate that they do not notice odors in the facility as housekeeping Staff is cleaning on a daily basis. Interviews with Staff indicate that there are odors at times but Staff immediately cleans and removes the source of the odor. LPA toured the facility including resident bedrooms receiving incontinence care and did not notice a smell of urine or any other type of odors.

Based on LPA record review, observations and interviews, investigation revealed: Although the allegations may have happened or is 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 conducted with Alexander Solorio and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC9099 (FAS) - (06/04)

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