198603286-3-2-2023-28-AS-FFIS-CQN2VX-20230406174440

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/02/2023
Date Signed: 03/02/2023 11:43:01 AM

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
02/23/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230223095854

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: 67	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Assistant Administrator- Alexander Solorio		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to resident resulting in resident wandering away from facility.

INVESTIGATION FINDINGS:

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

On 3/1/23, LPA Calderon called Pasadena Police Department to request documentation of an incident report, Deputy Veronica stated no report provided only incident number given: Incident number: #2314334.

During today's visit on 3/2/23, LPA obtained a copy of the Staff/Resident rosters, Resident #1's (R1) Admission Agreement, Physician Report, Face Sheet, Hospital Report and Unusual Incident Report. LPA interviewed Alex Solario, Staff #1 (S1) and attempt interview R1.

Continuation on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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-20230223095854

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: 03/02/2023

NARRATIVE

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In regards to the allegation: Staff did not provide adequate supervision to resident resulting in resident wandering away from facility. LPA Calderon interviewed Alex Solorio whom stated R1 is able to leave the facility unassisted and received care by the Hospital. LPA interviewed S1 who stated they knew R1 was going to the community and R1 is able to leave the facility. LPA attempt to interview R1, unsuccessful as R1 was out in the community for the day. LPA reviewed R1's Physician Report which states :Yes R1 Able To Leave Facility Unassisted.

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 was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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