198603286-4-24-2023-28-AS-MVAO-CTNSXV-20230712141633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 04/24/2023
Date Signed: 04/24/2023 03:47:57 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
04/18/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230418170117

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: 69	DATE:	04/24/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Alex Solorio		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident hit another resident with an object resulting in bruising.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Glenn Trueman conducted the initial 10-day complaint visit to investigate the above allegation. LPA met with Assistant Administrator Alex Solorio and discussed the purpose of today's visit.
During this visit, LPA obtained a copy of the resident roster, staff roster, Reviewed Resident #1 (R1's) file and obtained relevant documentation: R1's Face Sheet, R1's Physician Report, R1's Appraisal, R1's Needs and Service Plan, Special Incident Reports (SIR's), SOC 341, Hospital Documentation and 30 Day Eviction Notice and Pasadena Police Department Report# PA2023-30741.
Interviews were conducted with Assistant Administrator and Staff S 1 and S 2 from 1:15 to 2:20 PM.
Interviews were conducted with Resident's R 1 and R 2 from 2:25 to 3:00 PM.
In regards to the allegation Resident hit another resident with an object resulting in bruising, based on interviews conducted and information gathered it was revealed in interview with Assistant Administrator that Resident R 1 without warning grabbed a chair and threw it at Resident R 2. Stated that law enforcement was called and video footage showed R 1 throwing the chair. Stated that Staff S 1 was close by and ran to

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20230418170117

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: 04/24/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

incident within seconds and he ran to the incident right away.
Said R 1 was still aggressive throwing rocks at the facility window and also being aggressive to staff.
Stated that R 1 was sent for a psych evaluation, law enforcement was called and SOC 341, SIR and eviction notice was submitted. Also moved R1 to a different location in the opposite side of the building from R 2.
Also provided First Aid for R 2 who had a minor skin tear and didn't need any additional medical assistance.
Staff S 1 stated that she was passing breakfast with her cart and was 4 rooms away and heard noise and looked and saw R 1 throw a chair at R 2. Said she dropped everything to go there within seconds and with her walkie talkie called for help and the Assistant Administrator arrived in less than a minute.
Staff S 2 said she was with Assistant Administrator and heard caregiver asking for help. Said Assistant Administrator ran right away and First Aid was given and psych evaluation requested,.
Interview was conducted with R 1 who stated he did throw a chair and staff helped right away and then he ran out .R 1 during course of interview also was saying random statements such as call Citibank and I will pay you 2 million dollars and that he lives in Burbank and gave a different last name.
R 1 said you have the facts and ended the interview not wanting to speak anymore.
R 2 stated that R 1 threw a chair at him after he called him loco when R 1 called him stupid. Stated that it hit him in the leg and the caregiver came fast to help him and that R 2 ran away and went outside throwing rocks. Said police were called.

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 allegations are unsubstantiated.

Exit interview was conducted

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2