198603286-3-23-2023-28-AS-RORN-CRRT28-20230512142020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/23/2023
Date Signed: 03/23/2023 01:58:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/17/2023 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230317151530

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:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Alexander Solorio/Assistant Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff do not provide adequate food service to resident
Staff are not meeting resident's dietary needs
Staff do not assist resident with toileting needs
Staff do not respond to resident's calls for assistance
Staff do not provide water to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with Alexander Solorio and discussed the purpose of today's visit.

During this visit, LPA obtained a copy of the resident roster, staff roster, menus and shift-to-shift reports/notes. LPA reviewed Resident #1 (R-1's) file and obtained relevant documentation. LPA interviewed the Assistant Administrator, Staff #1 (S-1) through Staff #3 (S-3) and Resident #1 (R-1) through Resident #7 (R-7). LPA also conducted a tour of the kitchen.

Refer to LIC 9099C for the continuation of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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-20230317151530

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 03/23/2023

NARRATIVE

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Allegation: Staff do not provide adequate food service to resident. Staff interviews revealed that staff provide adequate food service to residents. Staff indicated they follow a menu and also provide alternative food items for residents. Staff interviews revealed they have only received complaints from R-1 about R-1’s food. Per Staff interviews, R-1 alleges that the food provided has pepper in which R-1 alleges to be allergic to. Per Staff, R-1 requests to have baked chicken, baked potato, rice and bread for R-1’s meal and when R-1 does not like it, R-1 throws it away. Interviewed staff indicated that R-1’s meals are prepared as per R-1’s request (with no pepper/no chili). Per Staff, R-1 is also offered fruits/snacks daily. Interviews Residents indicated the staff provide adequate food service including snacks and do not have any concerns. Interviewed Residents indicated that the food portions and options are adequate. Interviews do not corroborate this allegation.

Allegation: Staff are not meeting resident's dietary needs Staff interviews revealed that staff meet residents’ dietary needs. Per interviewed staff, kitchen staff are aware of the Residents dietary needs. Staff interviews revealed that there is a board in the kitchen which reflects Residents dietary needs (diabetic, no/low salt, food allergies, preference, ect). LPA toured the kitchen and observed this board posted. Per Staff interviews and R-1’s file review, R-1 is not on a special diet. However, per staff interviews, they have R-1 noted as having a “preference of no pepper/chili pepper or any pepper” noted. Interviewed Residents indicated staff are meeting residents’ dietary needs. (4) out of (7) interviewed Residents are on a diabetic diet. Interviewed Residents indicated they do not have any concerns in regards to their diets. Interviews do not corroborate this allegation.

Allegation: Staff do not assist resident with toileting needs Staff interviews revealed that staff assist/meet residents’ toileting needs. Interviewed staff indicated they conduct rounds every (2) hours and check if residents need assistance with toileting needs and/or incontinence care. Staff indicated they have a list of Residents that require assistance with incontinence needs and do not have a log of when the rounds are conducted. Staff interviews revealed they have only received complaints from R-1 about R-1’s alleging that R-1’s toileting needs are not being met. Per staff interviews, R-1 “refuses to be touched” and staff attempt to assist R-1 as much as possible. (6) out of (7) interviewed Residents indicated staff conduct rounds often and provide assistance/incontinence care every (2) hours. Interviewed Residents indicated they do not have concerns with staff meeting their toileting needs. Interviews do not corroborate this allegation.

**Refer to LIC 9099C for the continuation of this report.**

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230317151530

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 03/23/2023

NARRATIVE

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Allegation: Staff do not respond to resident's calls for assistance Staff interviews revealed that staff respond to Residents calls in a timely manner. Interviewed Staff indicated they have not received any concerns/complaints from anyone in regards to staff not responding to residents calls for assistance. (6) out of (7) interviewed Residents indicated staff respond to their calls in a timely manner. Interviewed Residents indicated they do not have concerns with staff not responding to their calls. Interviews do not corroborate this allegation.

Allegation: Staff do not provide water to resident Staff interviews revealed that staff provide water to residents. Staff interviews revealed they have only received complaints from R-1 about R-1’s not receiving hot water. Per Staff interviews, R-1 is provided with hot water as per R-1’s request. Per Staff interviews, R-1 only consumes hot water and when it cools off, R-1 requests hot water which is provided to R-1. Interviewed staff have not received concerns/complaints from other Residents in regards to staff not providing residents with water. (6) out of (7) interviewed Residents indicated staff provide Residents with water. Interviewed Residents indicated they do not have concerns with staff not providing residents with water. Interviews do not corroborate this allegation.

Although the allegation(s) 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.

Exit interview was conducted, Appeal Rights and a copy of this report was provided to Alexander Solorio/Assistant Administrator

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

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