198603286-2-10-2023-28-AS-MVAO-CPKT3R-20230303132248

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 02/10/2023
Date Signed: 02/10/2023 02:27:07 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
02/08/2023 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230208131648

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: 65	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Alexander Solorio (Assistant Administrator)		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained an injury while in care and staff did not seek timely attention.
Staff failed to provide a safe environment for resident.
Staff failed to meet resident's medical needs.

INVESTIGATION FINDINGS:

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

During today's visit, LPA obtained a copy of the Staff/Resident rosters, Resident #1's (R#1) Physician's report, tree cutting invoice, Medication log and Hospital records. Toured the patio area with Staff #1. Interview Staff #1 to #4 in the office and interviewed Residents #2 to #7 in the office.

In regards to the allegation: Resident sustained an injury while in care and staff did not seek timely attention. It was alleged that a tree branch located in the patio area fell on R#1 but Staff did not seek timely attention. On 01/23/23 a tree branch fell on R#1 and Staff was made aware of the incident. Staff immediately assisted R#1 and called the paramedics. Paramedics arrived a few minutes later and transported R#1 to the hospital. Per hospital records, R#1 did not sustain serious injury. 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: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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-20230208131648

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: 02/10/2023

NARRATIVE

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In regards to the allegation: Staff failed to provide a safe environment for resident. It was alleged the a tree located in the patio area of the facility was not properly maintained which resulted in a tree branch falling on R#1. Interviews with 4 of 4 Staff indicate they did not notice the patio tree to be in bad condition. Interviews with 6 of 6 Resident indicate they did not notice the patio tree to be in bad condition and feels safe in the facility. Staff and Residents also indicate they are not aware of the condition of the tree until the tree was cut down which revealed rotting inside the tree. LPA toured the patio area and observed the tree was removed.

In regards to the allegation: Staff failed to meet resident's medical needs. It was alleged that R#1 was diagnosed with a new medical condition prior to returning from the hospital and facility failed to assist R#1 with obtaining medications for the new diagnosis. Review of R#1's Physician report and hospital records does not indicate a diagnosis of any new medical conditions therefore new medications were not needed. Interviews with 6 of 6 Residents indicate their medical needs are met.

Based on LPA's interviews, record review and observations, the 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: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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