198603286-7-7-2023-28-AS-MVAO-CTPQK9-20230713121358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/07/2023
Date Signed: 07/07/2023 11:44:35 AM

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
11/18/2022 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221118141004

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: 72	DATE:	07/07/2023
		UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Alex Solorio - Assistant Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Illegal eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegation of "Illegal evitcion". Upon arriving at the facility, LPA met with Resident Care Director / Maria “Luisa” Razo and Assistant Administrator Alex Solorio.

The investigation consisted of the following: LPA Alberto Lopez conducted a prior visit to this facility on 11/23/22 in reference to the allegation listed above. During the course of the investigation an interview was conducted with Assistant Administrator / Alexander Solorio and copies of the following documents were obtained and reviewed: • Resident Roster • Staff Roster • 30 Day Termination Notice for R1

During todays investigation LPA Tena Herrera attempted to interview R1, however, R1 has been evicted from facility and LPA was unable to get ahold of resident. During todays visit LPA obtained copies of the following: • Resident Roster • Staff Roster • House Rules • Facility's 30 Day Termination Notice for R1 • Court Ordered Eviction Notice • Unusual Incident/Injury Reports involving R1 • Physicians Report for R1

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

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-20221118141004

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: 07/07/2023

NARRATIVE

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LPA also conducted interviews during todays visit with Assistant Administrator Alex Solorio, Resident Care Director Maria "Luisa" Razo and S1.

The investigation revealed the following:
Allegation: Illegal Eviction. The details of this allegation states that R1 is being illegally evicted. Based on interviews conducted the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. After reviewing the file of R1, LPA discovered that R1 was issued a 30 Day Eviction Notice on 10/20/22, for breaking facility house rules and failing to pay rent. During the period of 9/1/22 - 10/20/22, R1 was observed violating house rules by having possession of an illegal substance and being verbally and physically abusive towards staff and other residents. R1 also stopped paying rent and had an outstanding balance of $1,620.46 owed to the facility. R1's last day at the facility was on 4/27/23. Based on the information gathered, there is insufficient evidence to support the above allegation to be true.

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.

An exit interview was conducted and a copy of this report was provided to Assistant Administrator Alex Solorio.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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