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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/07/2023
Date Signed: 03/07/2023 01:19:24 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
02/27/2023 and conducted by Evaluator Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230227093847
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: 66DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Alexander Solorio (Assistant Administrator)TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff did not provide resident adequate supervision resulting in resident wandering away from the facility.
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/reviewed a copy of the Staff/Resident rosters, Resident #1's (R#1) Physician's Report, Appraisal/Needs and Services Plan and Preplacement Appraisal Information. LPA also interviewed Staff #1, #2 in the office and attempted to interviewed R#1 but R#1 is currently out of state and was not available to be interviewed.

In regards to the allegation: Facility staff did not provide resident adequate supervision resulting in resident wandering away from the facility. Interviews with Staff #1 and #2 indicate R#1 is able to leave the facility unassisted and does not have wandering behaviors. Review of R#1's record indicate R#1 does not have wandering behaviors and is able to leave the facility unassisted. Continue to LIC9099C.....
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
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 2
Control Number 28-AS-20230227093847
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: 03/07/2023
NARRATIVE
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Based on LPA's interviews and record review, the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Alexander Solorio and a copy of this report provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2