198603286-3-21-2023-28-AS-MVAO-CTNSPB-20230712140251

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/21/2023
Date Signed: 03/21/2023 02:43:56 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
03/17/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230317135930

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:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Alexander Solorio, Assistant Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff are retaliating against resident for complaining.
Staff do not ensure residents are prohibited from smoking when oxygen is in use.
Staff does not ensure resident is accorded privacy during phone calls.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit in reference to the above allegations. LPA met with Assistant Administrator Alexander Solorio.

The investigation consisted of the following: A tour of the interior and exterior physical plant was conducted. The physical plant tour focused on observation of rooms in which there are resident smokers and/or there is Oxygen in use. Staff (S1- S5) and residents (R1 - R10) were interviewed. The following documents pertaining to R1 were reviewed and obtained: Identification and Emergency Information, Preplacement Appraisal Information, Functional Capability Assessment, Resident Appraisal, Care Plan, Appraisal/Needs and Services Plan, Physician Report, House Rules, and Admission Agreement. Resident resident roster, and LIC 500 Personnel Report. Resident (R2's) Behavior Contract, resident rosterm and LIC 500 Personnel Report were also obtained.

See LIC 9099C for report continuation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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 3

Control Number 28-AS-20230317135930

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: 03/21/2023

NARRATIVE

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Allegation: Staff are retaliating against resident for complaining. It is alleged that facility staff are retaliating/harassing resident (R1) because on 3/17/2023 the resident was provided a 2nd copy of the House Rules after filing a previous complaint with Community Care Licensing. According to staff interviews conducted, the findings indicate that the resident has history of smoking cigarettes in the room and during a prior CCL visit conducted by another LPA it was noted that R1's room had a strong marijuana odor. All staff denied the allegation, but confirmed the No Smoking policy has been addressed with the resident in a non-retaliatory manner. A total of 10 residents were interviewed. Two (2) out of the 10 residents stated that administration staff have retaliated against them in instances in which they complain about other residents, and/or when they complain about staffing not doing their job after daytime hours. The facility House Rules state "In order to promote a healthy environment in the facility, we have established a "No Smoking" policy in ALL INDOOR common areas and rooms. Smoking is however, permitted in the designated smoking areas only. The "No Smoking" policy includes all elevators, hallways, stairwells, public restrooms, courtyards, and patios." Therefore, there is in insufficient evidence to corroborate the allegation.

Allegation: Staff do not ensure residents are prohibited from smoking when oxygen is in use. It is alleged that there is a resident that lights up cigarettes in its room and there is oxygen tanks in the room. The findings revealed that resident (R2) has been observed by staff and residents smoking inside the room, in which there in oxygen in use. According to Assistant Administrator, R2 has been observed lighting a cigarette in the room and walking out of the room to go smoke in the outdoor designated smoking area. Three (3) out 10 residents stated they have observed R2 smoke in the room where oxygen is in use. The residents confirmed that R2 has been addressed regarding the No Smoking policy and Oxygen Use. Staff stated that when and if they observe any resident smoking indoors they are immediately reminded that smoking is prohibited indoors. In addition, staff are trained to watch out for indoor smoking by residents. Per staff interviews, on 2/2/2023 resident (R2) was issued a Behavior Contract that discussed House Rules, No Smoking policy, and smoking area escort assistance. Staff are closely watching the resident to ensure no indoor smoking is being done.

See next page.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230317135930

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: 03/21/2023

NARRATIVE

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Allegation: Staff does not ensure resident is accorded privacy during phone calls. It is alleged that on 3/17/2023, the Assistant Administrator attempted to eavesdrop on R1's phone conversation, and was overheard asking hospice staff to tell him if the resident was making a call to Community Care Licensing. A total of five (5) staff were interviewed. All denied the allegation by stating that residents are always accorded privacy while they are using their phones in their rooms, lobby areas, and when they use the facility wireless telephone. Three (3) out of 10 residents stated that Administrator and staff seem to target specific residents. For instance, a resident stated that staff do not knock at the door or announce themselves and enter while they are talking on the phone. Another resident stated that Administrator seems to eavesdrop only on certain people. However, the majority of the residents stated that they are afforded privacy by facility staff, and that Administrator does not eavesdrop, but rather stops by the resident rooms to see how they are doing. LPA observed a wireless facility phone in the lobby area, and another phone located in the private marketing office that can be used by residents. There is insufficient evidence to support the allegation.

Although the allegation(s) 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.

No Deficiencies cited under California Code of Regulations Title 22

Exit interview was conducted with Assistant Administrator Alexander Solorio. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

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