198603286-6-30-2023-28-AS-RORN-CTWRG2-20230720125959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 06/30/2023
Date Signed: 06/30/2023 02:28:23 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
03/14/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220314170054

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:	06/30/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Resident Care Director / Maria “Luisa” Razo		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Allegation: Lack of supervision resulting in resident's engaging in an altercation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegation of "Lack of supervision resulting in resident's engaging in an altercation”. Upon arriving at the facility, LPA met with Resident Care Director / Maria “Luisa” Razo who assisted with the visit.

LPA Katrdzhyan conducted prior visits to this facility on 3/16/22 and 6/28/23, in reference to the allegation listed above.

During the course of the investigation, interviews were conducted of various persons to include the Assistant Administrator / Alexander Solorio, Staff members 1 through 5 (S1 - S5) and Residents 1 through 4 (R1 – R4). Also, copies of the following documents were obtained and reviewed in reference to R1 and R2;

• Appraisal/Needs and Services Plan • Physician's Report • Unusual Incident/Injury Report / LIC 624.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

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-20220314170054

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: 06/30/2023

NARRATIVE

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The investigation revealed the following;

Allegation: Lack of supervision resulting in resident's engaging in an altercation.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. The alleged incident happened on 3/12/22, at approximately 9am. R1 was observed by S1 standing in front of R4’s door (in the hallway) having a verbal argument with R4. S1 intervened by de-escalating the situation and asked R1 to go back to his room. As R1 was going to his room, R2 came out of his room (nearby) and began yelling at R1 by saying, “you can’t be talking to R4 like that” and pushed R1 to the floor. S1 immediately intervened and separated both Residents and called S2 and S3 for help. R1 and R2 were separated and escorted back to their separate rooms. Shortly after, R1 and R2 went outside in the patio area (near their rooms) and began arguing a second time and S1, S2 and S3 immediately intervened and helped de-escalate the situation. The Pasadena Police Department was involved and spoke with both residents and no arrests were made or charges filed. R1 and R2 did not sustain any injuries, as a result of both incidents. The Assistant Administrator spoke with both residents after the incidents and asked them to stay away from each other to avoid further confrontations. R1 and R2 are independent and do not require one to one supervision. Although it appears an altercation did occur between R1 and R2, staff intervened immediately, conducted body checks and called the Police. All agencies were notified of the incident (via SOC 341). Therefore, there is insufficient evidence to indicate a lack of supervision on the part of the facility. 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 the Resident Care Director.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC9099 (FAS) - (06/04)

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