198603286-7-27-2022-28-AS-RORN-CKBUC8-20221018152730

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/27/2022
Date Signed: 07/27/2022 03:28:53 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
07/19/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220719101626

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:	07/27/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Staff / Maddison Aceves Assistant Administrator / Alexander Solorio		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident has access to marijuana while in care.

Resident has access to alcohol 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 Staff / Maddison Aceves and was later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegations of "Resident has access to marijuana while in care and Resident has access to alcohol while in care".

During today's visit, LPA interviewed the Assistant Administrator, Staff members 1 - 3 (S1 - S3) and Residents 1 - 3 (R1 - R3). Interview of S1 was conducted via telephone. Also, copies of the following documents were obtained and reviewed in reference to R1;

• Resident Identification and Emergency Information Sheet • Physician's Report • Facility Internal Incident/Accident Reports • Thirty Day Termination Warning • House Rules
(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: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

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-20220719101626

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: 07/27/2022

NARRATIVE

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The investigation revealed the following;

Allegations: Resident has access to marijuana while in care and Resident has access to alcohol while in care.
On 7/17/22, at approximately 5:50pm, there was an incident involving R1. S1 was on shift and conducting a walk through of the facility and checking on residents when S1 noticed R1 was smoking marijuana and drinking beer in the designated smoking area (back end of the facility). S1 also noticed a bag containing additional marijuana on top of the table, where R1 was sitting. S1 reminded R1 of the facility house rules and asked R1 to dispose the marijuana. S1 than confiscated the bag containing the marijuana and locked it in the front office and reported the incident to facility management. On 7/18/22, R1 called the Pasadena Police Department and reported theft regarding the marijuana. The Pasadena Police Department made a visit to the facility and spoke with R1 and S1 and reminded R1 of the facility house rules and asked R1 not to smoke or sell marijuana inside the facility. No further action was taken by the Pasadena Police Department.
Based on interviews conducted and documents reviewed, LPA learned that R1 had concerns related to substance abuse around the time of admission (in 2020), but had been doing better until recently.

LPA reviewed the Physician's Report for R1 and discovered that R1 is independent and able to leave the facility unassisted. R1 is also able to store and administer own medications and manage cash resources.
During the interview of R1, R1 admitted to purchasing marijuana from marijuana dispensaries while being out in the community and occasionally using it inside the facility and selling it to residents. R1 also stated that facility staff have given him multiple verbal warnings and discussed the facility house rules explaining that the use and sell of marijuana is prohibited. On 6/30/22, R1 was issued a "Thirty Day Termination Warning' for breaking facility house rules by continuing to use marijuana inside the facility. As a result of the latest incident which occurred on 7/17/22, the Assistant Administrator stated that R1 will be issued a "30 Day Eviction Notice" on 7/28/22, for failing to comply with facility house rules and nonpayment of rent. Based on the information gathered, there is insufficient evidence to support these allegations to be true.

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.

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: 07/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022

LIC9099 (FAS) - (06/04)

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