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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/25/2022
Date Signed: 08/25/2022 04:12:39 PM

Substantiated


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
08/16/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220816120208
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: 60DATE:
08/25/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility door is too cumbersome for residents in wheelchairs to open.

Residents soiled linen is not changed timely.
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 who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegations of "Facility door is too cumbersome for residents in wheelchairs to open and Residents soiled linen is not changed timely."

During today's visit, LPA interviewed the Assistant Administrator, Staff members 1 and 2 (S1 & S2) and Residents 1 - 6 (R1 - R6). Also, a random selection of resident rooms were toured.

The investigation revealed the following;
Allegation: Facility door is too cumbersome for residents in wheelchairs to open. The details of this allegation states that the fire doors that exit to the back patio (where residents take breaks) are too heavy for residents in wheelchairs to open. (please see LIC 9099C for additional information)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
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 5
Control Number 28-AS-20220816120208
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: 08/25/2022
NARRATIVE
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Based on interviews conducted the statements obtained were consistent and corroborated with the allegation. Residents and staff interviewed confirmed that the fire doors that exit to the back patio (where residents take breaks) are too heavy for residents in wheelchairs to open. Often times, residents will wait on staff to come and open the doors for them because they are unable to keep the door open and wheel themselves out at the same time. During today's visit, LPA tried opening the fire doors that exit to the back patio and observed the weight of the doors and based on LPA's observation, it would be very difficult for anyone in a wheel chair to hold the door open and wheel themselves out at the same time.
Based on interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true.

Allegation: Residents soiled linen is not changed timely. Based on interviews conducted, the majority of statements obtained were consistent and corroborated with the allegation. Residents confirmed that linens and bed sheets are not changed regularly and often times residents have to request for their linens to be washed/changed because staff will not change them. There have been times where residents linens and bed sheets have not been changed for more than two weeks. During today's visit, LPA toured a random selection of resident rooms and observed the linens in rooms 33, 34B, 38B and 36B were soiled/dirty. Blood stains were observed on the linens in rooms 34B and 38B and on the pillow case in room 33. The pillow case in room 36B was torn and covered in stains. Based on majority of the interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true.

Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220816120208
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2022
Section Cited
CCR
87468.2(a)(14)
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Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities... To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents.
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Administrator will develop a plan and make corrections to the exit doors making them easily accessible for residents in wheelchairs and submit proof of correction to CCL by the POC due date.
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The requirement is not met as evidenced by; Residents and staff interviewed confirmed that the fire doors that exit to the back patio are too heavy for residents in wheelchairs to open. Often times, residents will wait on staff to come and open the doors for them because they are unable to keep the door open and wheel themselves out at the same time. During today's visit, LPA tried opening the fire doors that exit to the back patio and observed the weight of the doors and based on LPA's observation, it would be very difficult for anyone in a wheel chair to hold the door open and wheel themselves out at the same time.
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Type B
09/01/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities.
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
The requirement is not met as evidenced by:
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Administrator will develop a plan ensuring all resident beds have required bed linens and are washed regularly and submit plan of correction to CCL by the POC due date.
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Based on interviews conducted, the majority of statements obtained were consistent and corroborated with the allegation. Residents confirmed that linens and bed sheets are not changed regularly and often times residents have to request for their linens to be washed/changed because staff will not change them. There have been times where residents linens and bed sheets have not been changed for more than two weeks. During today's visit, LPA toured a random selection of resident rooms and observed the linens in rooms 33, 34B, 38B and 36B were soiled/dirty. Blood stains were observed on the linens in rooms 34B and 38B and on the pillow case in room 33. The pillow case in room 36B was torn and covered in stains.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/16/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220816120208

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: 60DATE:
08/25/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
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Facility did not replace resident's damaged wheelchair.

Trash in resident rooms are not being emptied often.

INVESTIGATION FINDINGS:
1
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3
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5
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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 who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegations of "Facility did not replace resident's damaged wheelchair and Trash in resident rooms are not being emptied often."

During today's visit, LPA interviewed the Assistant Administrator, Staff members 1 and 2 (S1 & S2) and Residents 1 - 6 (R1 - R6). Also, a random selection of resident rooms were toured.

The investigation revealed the following;
Allegation: Facility did not replace resident's damaged wheelchair. The details of this allegation states that the fire door that exits to the back patio is too narrow and damaged the wheelchair of Resident (the break rubbed on the door causing it to break). (please see LIC 9099C for additional information)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220816120208
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: 08/25/2022
NARRATIVE
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Based on interviews conducted the statements obtained were inconsistent and did not corroborate with this allegation. During the interview of Resident 1 (R1), R1 was not able to identify the date & time of the incident in order for LPA to review the surveillance camera at the facility and see the details surrounding the incident. According to the Assistant Administrator, he was informed of the incident from R1 and offered to call R1's insurance company to have it replaced but R1 refused as she handles her own concerns. The Assistant Administrator offered to give R1 a loaner wheelchair but R1 refused. The Assistant Administrator was unsure if the incident occurred at the facility as R1 did not provide a date and time of the incident. According to R1, R1 was hospitalized about a month ago and the hospital replaced her old wheelchair by giving her a new one. During today's visit, LPA observed R1 using a new wheelchair. Based on the information gathered, there is insufficient evidence to support this allegation to be true.

Allegation: Trash in resident rooms are not being emptied often. The details of this allegation states that Residents soiled diapers are not emptied often from the trash container inside of resident’s room.
Based on interviews conducted the statements obtained were inconsistent and did not corroborate with this allegation. Residents and Staff interviewed confirmed that trash is emptied in resident rooms regularly, which is once a day or as needed. Soiled diapers are not disposed in trash bins located in resident rooms and are disposed in the big trash bins located in the hallways, which are emptied during each shift. During today's visit, LPA toured a random selection of resident rooms and did not observe trash and or diapers in the bins located in resident rooms. LPA did not observe an overflow of trash anywhere. Based on interviews conducted and LPA's observation, there is insufficient evidence to support this allegation 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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5