198603286-5-4-2023-28-AS-FFIS-CT2SPZ-20230622140359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:21:46 PM

Unsubstantiated

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
04/26/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230426130601

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: 77	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Assistant Administrator -Alexander 'Alex' Solario		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident is not being provided mail.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander Solorio (Assistant Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters. LPA Interview Assistant Administrator Alexander Solario, Staff #1,#2 and #3 (S1,S2,S3), LPA attempt to interview via telephone R1 and interviewed Resident #2-8 (R2-R8). LPA Calderon along side with Assistant Administrator Alexander 'Alex' Solario toured areas were Mail is distributed.

In regards to allegation: Resident is not being provided mail.LPA Calderon interview with staff Alex and S1-S3 all who denied the above allegation and stated mail is being distributed to residents daily when mail comes in.
(Continuation on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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-20230426130601

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: 05/04/2023

NARRATIVE

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Interview with residents R2, R4,R6-R8 all denied above allegation and stated their mail is received and is not open or altered with. Interview with R3 and R6 stated their mail isn't sent to the facility and the above allegation does not pertain to them. LPA Calderon observed with Alex two areas were mail is distributed, mail box is locked, and side door of the facility has a Security Code/ Amazon Key Business Box for packet drop off. LPA Calderon observed mail packets having labels placed and mail was sealed.

Although the allegation 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 allegation are unsubstantiated.

Exit interview was conducted and a copy of today's report was provided to Alexander Solario, Assistant Administrator.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

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