198603286-5-16-2023-28-AS-RORN-CSDTVB-20230601150339

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:32:45 PM

Substantiated

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
05/08/2023 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230508090902

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: 74	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Staff / Maddison Aceves Assistant Administrator / Alexander Solorio		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff unlawfully evicted resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Maddison Aceves and was later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Staff unlawfully evicted resident in care".

During today's visit, LPA interviewed the Assistant Administrator and Resident #1 (R1), via telephone. Also copies of the following documents were obtained and reviewed;

• Physician’s Report • Unusual Incident/Injury Reports • Appraisal/Needs and Services Plan • Admission Agreement • Email chains between Clinical Psychologist, Assistant Administrator and Clinical Program Manager from ODR.

Please see LIC 9099C for additional information.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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-20230508090902

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: 05/16/2023

NARRATIVE

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The investigation revealed the following;

Allegation: Staff unlawfully evicted resident in care. Based on interviews conducted, LPA discovered that R1 was unlawfully evicted from the facility and an eviction notice was never issued to R1. Statements obtained from the Assistant Administrator and R1 corroborated that R1 was not allowed back at the facility after being hospitalized on 5/2/23. R1 is no longer residing at Pasadena Villa Senior Living.

During the course of the investigation, LPA discovered that on 5/2/23, R1 was placed on a 5150 hold due to having erratic behaviors and being a danger to himself and others. R1 was transported to Los Angeles Downtown Medical Center (LADMC) and admitted for a psychiatric evaluation. On 5/3/23, the Assistant Administrator received a call from LADMC, stating that they wanted to extend R1's stay for a total of 14 days.
On 5/5/23, the Assistant Administrator learned that R1 was transferred to Beverly Community Hospital (BCH). The Assistant Administrator called BCH to obtain additional information and was told that R1 was ready to leave the hospital against medical advice and would possibly be returning back to Pasadena Villa Senior Living. According to the Assistant Administrator, on 5/8/23, R1 arrived at the facility but staff refused to let R1 stay at the facility or remove his belongings. R1's Clinical Psychologist and Executive Director / Kandice Vergara arranged a meeting with R1 and R1 was issued a check for $2,500 to help pay for R1's stay at a hotel/motel until R1's Clinical Program Manager at ODR (Office of Diversion and Reentry) would find R1 placement elsewhere, as R1 required higher level of care. On 5/9/23, R1's personal belongings were placed in a storage in Van Nuys. On 5/16/23, the Assistant Administrator received an email from the Clinical Program Manager at ODR, stating that R1 no longer wants to be part of the ODR program. During the telephone call with R1, LPA learned that R1 is currently renting a room and living by himself.

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230508090902

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/23/2023 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility.	1 2 3 4 5 6 7	The Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, Section 87224. POC is due to CCL by the POC due date of 5/23/23.
	8 9 10 11 12 13 14	The requirement is not met as evidenced by: Based on interviews conducted, LPA discovered that R1 was unlawfully evicted from the facility and an eviction notice was never issued to R1. Statements obtained from the Assistant Administrator and R1 corroborated that R1 was not allowed back at the facility after being hospitalized on 5/2/23. R1 is no longer residing at Pasadena Villa Senior Living.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

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