198603286-5-5-2023-28-AS-RORN-CSCQKM-20230531121434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:57:43 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
04/28/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230428085434

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: 76	DATE:	05/05/2023
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Administrator, Alexander Solorio		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff mishandled residents' food items.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Administrator Alexander Solorio and explained the reason for the visit.

The investigation consisted of the following: LPA requested copies of Resident & Staff Rosters and conducted a tour of facility such as common areas, including the kitchen. LPA reviewed files for Resident #1 (R1) and requested copies of the following documents: Identification and Emergency Information Sheets, Physician Reports, Resident Personal Property and Valuables Sheet and Resident Appraisal. LPA also interviewed Staff #1 (S1) - Staff #3 (S3), and Resident #2 (R2) - Resident #6 (R6). Attempted to interview Resident #1 (R1) but unsuccessful due to R1 out of the facility for a few days for evaluation.

*****CONTINUED ON LIC 9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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-20230428085434

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: 05/05/2023

NARRATIVE

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The investigation revealed the following: in regards to the allegation "Facility staff mishandled residents' food items", it is alleged that resident had to remove all of the food stuffs, cold and frozen in the kitchen in less than 24 hours. S1 indicated that residents are allowed to bring their own refrigerator in their rooms to store their food at no extra charge However, S1 indicated that they only store food provided by the facility's contracted vendors in the kitchen's refrigerators/freezers. This is to avoid any food cross-contamination that may cause illnesses to the residents. S1 spoke to R1 on 4/27/2023 personally and explained to him that he has to take his food out of the kitchen storage due to food safety and handling requirements. According to S1 he offered R1 (3) options and agreed to hold R1's food temporarily. S1-S2 transferred R1's food to the big refrigerator in the facility's back storage area. And R1 was given 2-3 days to hold the food at no extra charge and R1 agreed. Other staff members interviewed stated that they do not keep outside food in the kitchen's refrigerator/freezer for safety and to prevent cross-contamination of food. Residents interviewed indicated they were not aware of the allegation. Residents stated that they never asked any kitchen staff to keep the food that they purchased outside. Residents stated that the facility provide enough meals to them daily and they only purchase snacks and fruits if they have extra money. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 held, and a copy of this report was provided to the Administrator, Alexander Solorio.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

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