198603286-3-14-2023-28-AS-RORN-CQTLE4-20230412084053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/14/2023
Date Signed: 03/14/2023 03:22:54 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
03/06/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230306153126

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: 69	DATE:	03/14/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Assistant Administrator - Alexander 'Alex' Solorio		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident call buttons are in disrepair.
Staff are not meeting residents laundry needs.
Staff are not meeting residents showering needs.
Facility dryer is in disrepair.
Staff are not meeting residents bedding needs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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.

During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters, Resident #1 (R1) Physician Report, R1's Needs and Appraisal Plan, R1's Admission Agreement,R1's Care Plan, R1's Special Incident Reports (SIR), R1's Call Light Pendant Agreement,facilties laundry Schedule and Shower/Bedding Schedule.LPA interviewed Assistant Administartor and Staff #1- #4 (S1-S4) . LPA Calderon attempt to interview R1, interviewed Resident #2-#5 (R2-5). LPA toured along side with Luisa Razo laundry room and LPA tested residents call buttons.

Continuation on LIC9099D...

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: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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 3

Control Number 28-AS-20230306153126

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: 03/14/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

In regards to allegation: Resident call buttons are in disrepair. LPA Calderon interview staff, Alex and S2-S4 all denied above allegation stated some resident's have pendants for call buttons and in addition staff do rounds to check on residents. LPA Calderon interview residents R2-R4, all denied above allegation and stated call button are pendants and work. LPA observed and tested resident call button pendants and were functional and operable. LPA also observed a purchase of new pendants that will be distributed to residents once activated. LPA reviewed R1's documentation on Pendant Agreement / Responsibility.

In regards to allegation: Staff are not meeting residents laundry needs.LPA interviewed S1 and S2 who do not work in the laundry services and laundry services are not part of their job duties. LPA interviewed Alex, S3 and S4 all who denied above allegation and stated laundry is done weekly, there is a laundry schedule and laundry if needed more if residents are soiled staff will assist. LPA interview resident R2-R4 all denied above allegation and stated their laundry needs are met and staff do laundry service for residents.LPA collected and reviewed Laundry Schedule, residents received laundry services once a week on schedules days and LPA toured laundry room and observed laundry being done for residents in care.

In regards to allegation:Staff are not meeting residents showering needs. LPA Calderon interviewed staff Alex, S4 and S3 denied above allegation and stated resident's have shower days twice a week or as needed if requested based on solid incidents. Alex stated upon second shower of the week refusal facility documents refusal and resident's sign documentation. LPA Calderon interviewed resident R2-R4 and all denied allegation stating they take showers, they receive towels and have scheduled shower days if assistance is needed. LPA Calderon observed and reviewed Shower Schedule, residents are scheduled to receive showers twice a week. LPA reviewed R1's SIRs on shower incidents, R1 refused shower and LPA reviewed facility documentation on R1's shower refusals.

In regards to allegation:Facility dryer is in disrepair. LPA Calderon interviewed staff Alex and S1-S4 all denied above allegation and stated dryer machines are operable. S1 stated during interview S1 checks on laundry machines regularly for any needed repairs and facility is scheduled to receive new commercial washer and dryers. LPA interviewed resident R2-R4, all denied above allegation stating machines work, staff does laundry for residents.LPA observed laundry room, laundry machines were in use and functioning. Dryer machine was running and operable. Laundry room is used by staff only.

Continuation on LIC 9099D.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230306153126

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: 03/14/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

In regards to allegation: Staff are not meeting residents bedding need. LPA interview staff Alex and S3 and S4 all denied above allegation stated resident receive clean linen and bed sheet change based on shower schedule days and as needed. Interview with S1 and S2 stated job functions do not involve bedding services but machines are clean and operable to do laundry for linen. LPA interviewed resident R2-R4 all denied above allegation stated bed sheets are changed, and when requested for new cleaned staff provided bedding services. LPA reviewed Shower / Bedding Schedule. Residents are scheduled to receive showers twice a week and on scheduled shower days cleaning of bedding is scheduled for the same day. LPA Calderon reviewed R1's SIR on bedding incidents and SIR's state staff providing sheet change for R1's bed.
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 Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3