198603286-6-9-2021-28-AS-CYEE-C783LU-20210925182118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 06/09/2021
Date Signed: 06/09/2021 01:28:28 PM

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
06/03/2021 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210603091021

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: 36	DATE:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Alexander Solorio-Assistant Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility is in disrepair
Facility will not provide resident with a copy of the admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)Christine Wong conducted an initial 10 days complaint to the above facility. LPA met with Assistant Administrator-Alexander Solorio and explained the purpose of the visit and he also assisted with the visit.

The investigation consisted of the following: LPA toured the facility and inspected room# 7, #10, #30 and #34 and there's no safety hazards were observed. LPA also interviewed four (4) residents (R2-R5) and four (4) staff (S1-S4)and obtained documents included staff and resident rosters, updated report from fire department.

The investigation revelaed of the following: Allegation#1 "Facility is in disrepair." LPA interviewed residents and all reported the facility is clean and nice and there's nothing disrepair in their rooms or in the facility. LPA interviewed staff and all reported no resident complained about the facility is in disrepair and if something happened, they will fix it right away. (Continuation of LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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-20210603091021

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: 06/09/2021

NARRATIVE

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For the sprinkler, administrator reported there was a fire in Room#19 about two weeks ago. The sprinkler in the room#19 was working but due to there's not enough smoke for the other rooms' sprinklers to be activated, the fire department also checked other rooms sprinklers on the same day and they are all operable.

Allegation#2 " Facility will not provide resident with a copy of the admission agreement." Administrator reported he just got the email from Resident#1 (R1) and requested the copy of the admission agreement the past weekend. Administrator stated R1 did talk about it before but never officially requested. LPA interviewed residents and they all reported staff are responsible and able to meet their needs. Staff are always able to provide what they needed and wanted.

Based on LPA observations and interviews, investigation revealed: 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.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator, Alexander Solorio

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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