198603286-3-13-2023-28-AS-RORN-CT7KRB-20230627080737

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/02/2023
Date Signed: 03/13/2023 01:10:53 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
10/27/2020 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201027140928

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: 67	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Alex Solorio		TIME COMPLETED:	04:57 PM

ALLEGATION(S):

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Resident developed multiple pressure injuries
Staff are not preventing the spread of infection
Staff are retaining a resident that requires a higher level of care
Staff does not ensure that resident receives adequate wound care

INVESTIGATION FINDINGS:

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**** This amended report supersedes report dated 03/02/2023. It was created to add additional interview responses of staff and residents on 9099C. The additional revision did not change any other aspects of the report and all aspects including the findings remain the same. ***
Licensing Program Analyst (LPA) Alberto Lopez made unannounced subsequent visit to investigate the above allegations. LPA Lopez met with Assistant Administrator Alex Solorio and discussed the purpose of the visit. Initial 10 day visit was conducted telephonically by LPA Joe Katrdzhyan on 10/27/2020
The investigations consisted of reviewing and obtaining relevant medical documentation from R1 and interviews with staff and residents.
Regarding allegation: Resident developed multiple pressure injuries.
Assistant Administrator S1 stated that resident arrived to the facility with pressure injuries and was receiving wound care from Pacific Pace and Mission Hospice at the time. 5/5 staff (S1-S5) stated that no

(CONTINUE ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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-20201027140928

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: 03/02/2023

NARRATIVE

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resident has developed a pressure injury while in care. LPA interviewed 2 residents with current wounds and 2/2 residents (R2-R3) stated they arrived at facility with wounds and did not develop them at the facility.
LPA also interviewed additional 5 residents (R4-R8). R4–R8 stated they do not know any residents with pressure injuries, and they do not have any. LPA reviewed documentation from Pacific Pace and Hospice along with R1 medical records and it documented R1 wound(s) prior to being admitted to facility.
Regarding Allegation: Staff are not preventing the spread of infection.

Assistant administrator S1 stated that they have an infection control plan. LPA reviewed infection control plan and all staff 5/5 stated they follow the plan to prevent infection. LPA observed a large bin in a secured area where all biohazard material is place for disposal. 5/5 stated they are specific procedures to prevent the spread of infection and denied ever walking or seeing others walk or step in biohazard infectious liquids. 2 of 2 of residents who currently received wound care stated that all biohazard material is disposed in proper manner. R4-R8 stated that facility does everything they can to prevent infection spread. LPA took tour of facility with assistant administrator and did not notice any infectious material or fluids anywhere in the facility rooms or common areas. LPA observed large container in locked closet where all biohazard material is placed for proper disposal by contractor Allegiance Specialty Pharmacy. LPA observed a sign on the container with “BIO-HAZARD” on it.

Regarding Allegation: Staff are retaining a resident that requires a higher level of care.

Assistant Administrator (S1) stated that facility does not retain residents that require higher level of care. S1 stated R1 came in at level 2 and the facility can care for residents up to level 4. When R1 arrived the facility, the facility along with Pacific Pace and Hospice provided all of resident’s needs. 5/5 staff interviewed stated they have not seen or know of any residents that require higher level of care residing at facility. 5 of 7 residents stated that they are happy with the care they receive and know of no other residents that requires higher level of care. 2 residents stated that one resident is loud and wish they had a room further away, but not sure resident requires higher level of care.

Regarding Allegation: Staff does not ensure that resident receives adequate wound care.

Assistant Administrator stated that facility, Pacific Pace and Mission Hospice was providing resident with proper wound care. LPA reviewed facility progress notes for R1 dated from 10/06/2020 to 03/21/2021 and it documented all care including wound care provided to R1. 5/5 staff interviewed stated that mostly all wound care is done by outside agencies like home health or Hospice and that facility ensured that R1 received proper wound care while at facility. 2/2 current residents that require wound care stated they are getting proper wound care and happy with the services. The other 5 residents R4-R8 stated they do not know anyone who receives wound care and unable to answer this question.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies noted nor any citations issued at this time.
Exit interview conducted and a copy of this report provided to Assistant Administrator Alex Solorio along with appeal rights.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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