198603286-3-16-2023-28-AS-TVAO-CSBUM9-20230530154157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/16/2023
Date Signed: 03/16/2023 02:28:53 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
03/10/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230310104544

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:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Alex Solorio, Assistant Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff failed to intervene in confrontation between residents.
Staff does not ensure resident's privacy is protected.
Staff threatened resident with eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced complaint investigation for the allegations listed above. LPA met with Assistant Administrator, Alex Solorio, and explained the purpose of the visit.

The investigation consisted of the following:
LPA obtained the staff roster, resident roster, and reviewed 2 resident files. Copies of Resident #1's (R-1) documents were obtained. LPA interviewed the Assistant Administrator, 4 Staff, and 6 Residents.

The investigation revealed the following:
Allegation - Staff failed to intervene in confrontation between residents. It is alleged that Resident #1 (R-1) had a confrontation with Resident #2 (R-2) and staff did not intervene. LPA interviewed the Assistant Administrator Solorio and 4 Staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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-20230310104544

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: 03/16/2023

NARRATIVE

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Staff who witnessed the incident, stated that R-1 wanted to talk to R-2’s roommate. Staff stated that R-1 became upset because R-2 was trying to prevent R-1 from having interaction with the roommate and verbally threatened R-2. Staff immediately intervened, told R-1 to step away, and tried to de-escalate the situation. Later that day, R-2 felt threatened again as R-1 attempted to visit the roommate and contacted the police without informing staff. Per Mr. Solorio, after the confrontation that occurred on 3/5/23, he contacted R-1's case worker to inform of the incident. They held a meeting with R-1 and placed resident on a behavior contract on 3/10/23. Staff interviewed stated they will intervene in any altercations between residents immediately upon hearing or seeing it occur. They want to make sure all residents are safe. 6 out of 6 residents interviewed have seen staff intervene whenever there are any altercations between residents. Based on information gathered, there is insufficient evidence to show that staff failed to intervene in confrontations between residents.

Allegation - Staff does not ensure resident's privacy is protected. It is alleged that staff allow residents to enter another resident's room without their permission. Staff interviewed stated they ensure residents are accorded privacy. They will knock and asked for permission before coming in. They are constantly monitoring residents to make sure they are safe and their privacy are respected. If they see a resident going to the wrong room, they will redirect the resident. However, they stated the residents are respectful and have seen them knock on the room door and ask for permission before they entered. 5 out of the 6 residents have not had anyone enter their room unattended and feels their privacy is protected here.

Allegation - Staff threatened resident with eviction. Per the Assistant Administrator, he has not threatened any residents with an eviction notice. He will explain to residents that certain behaviors and breaking the house rules could lead them to an eviction. Staff interviewed have not threatened to evict residents either. 5 out of the 6 residents interviewed have never been issued an eviction letter nor been threatened with one. One stated an eviction was issued due to not fully paying the rent.

Although the allegations 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.

An exit interview was conducted with Assistant Administrator Solorio. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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