198603286-5-26-2021-28-AS-LHIS-C6UUAG-20210914152439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 05/26/2021
Date Signed: 05/26/2021 01:50:20 PM

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
05/25/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210525104108

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: 35	DATE:	05/26/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Assistant Administrator / Alexander Solorio Executive Director / Kandice Vergara		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff did not protect resident from another resident
Staff did not safeguard resident's personal items
Staff does not have a sufficient amount of incontinence supplies

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegations. LPA met with Assistant Administrator, Alexander Solorio who assisted with today's visit.

Regarding the allegation that facility staff did not protect Resident #1 from Resident #2. The investigation consisted of interview(s) with Assistant Administrator, Executive Director, Resident #1, Resident #2, and review of facility surveillance video. The investigation revealed that on the evening of 5/23/21, Resident #1 stated that she was upset and went outside to the courtyard/smoking area. Video footage shows that Resident #1 was seated outside near Resident #2's room. Video footage and resident and staff interviews confirmed that resident #2 came out of his room through the sliding glass door which faces the courtyard. Video footage shows that resident #1 and resident #2 appeared to be having a conversation. Resident #1 stated that resident #2 went up to her, in his wheelchair, and touched her leg 3 times. Resident #2 stated that he touched Resident #1's leg because he was trying to console her. Resident #2 stated that he didn't touch Resident #1 in an inappropriate manner. LPA did not observe any inappropriate behavior in the video footage reviewed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

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-20210525104108

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: 05/26/2021

NARRATIVE

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Assistant Administrator, and Executive Director stated that Pasadena Police Officers came to the facility on 5/24/21 and interviewed residents, reviewed video footage, and spoke to Assistant Administrator. Pasadena Police indicated that there would be no further investigation.

Regarding the allegation that Staff did not safeguard Resident #1's personal items, specifically that Resident #3 is stealing Resident #1's incontinence supplies. And, Regarding the allegation that Staff does not have a sufficient amount of incontinence supplies.

The investigation consisted of interview(s) with Assistant Administrator, Executive Director, Staff #1, Resident #1, Resident #3, and review of facility's incontinence supplies.

Staff interviewed stated that they were not made aware by Resident #1 that Resident #3 was taking incontinence supplies. Staff interviewed stated that Resident #1 is independent, and does not use incontinence supplies to their knowledge. Staff #1 stated that resident #1 is in a program which provides her with additional supplies. Staff #1 stated that resident #1 stated that she voluntarily gives some of her incontinence supplies to other residents at the facility. Resident #3 denied that she has taken any incontinence supplies from Resident #1.

Staff stated that they have a sufficient amount of incontinence supplies. LPA toured facility with Assistant Administrator, and reviewed facility incontinence supplies. LPA observed a sufficient amount of incontinence supplies on today's visit.

Based on LPA's observations and interviews, investigation revealed: 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.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator, Alexander Solorio.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021

LIC9099 (FAS) - (06/04)

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