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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/11/2021
Date Signed: 08/11/2021 05:47:29 PM



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
08/06/2021 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210806121901
FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 33DATE:
08/11/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Gretel De SantiagoTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Illegal eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted the initial investigation for the allegation on illegal eviction. LPA arrived unannounced and met with Gretel De Santiago, Administrator Assistant and explained the purpose of the visit. Michael Murphy, Human Resources Director assisted LPA with the visit.

The investigation consisted of the following:
LPA obtained a copy of the staff roster and resident roster. LPA requested copies of the documents from Resident #1’s (R1) file: 30-day eviction letter, Appraisal/Needs and Services Plan, House Rules, and Facility notes/Usual Incident Reports. LPA also interviewed Kandice Williams, the Executive Director, 3 Staff, and 2 Residents.

(Continue on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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-20210806121901
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: 08/11/2021
NARRATIVE
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The investigation revealed the following:

Based on record review, Resident #1 (R1) was initially served a 30-day eviction letter on 5/5/21 and another most recently on 7/9/21. Per Executive Director, R1 had a physical altercation with another resident which led to the eviction notice served on 7/9/21. LPA interviewed R1 who denied the physical altercation and stated that the eviction letter was never provided to her. However, the incident was verified by staff through the video footage and the eviction letter served on 7/9/21 was signed by R1. Although LPA received documentation of incidents pertaining to R1, the specific incident(s) that caused for eviction were not indicated on the eviction letter. In addition, R1’s Appraisal/Needs and Services Plan has not been updated since 11/23/2020 to address the current behaviors. R1 is still residing at the facility.

Based on record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8, are being cited on the attached LIC 9099D.



An exit interviewed was conducted. The Plan of Corrections were reviewed and developed with the Executive Director. A copy of this report, LIC9099D, and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210806121901
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2021
Section Cited
HSC
1568.683(a)
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1568.683 Eviction notices; reasons for eviction contents, service (a)... a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.
This requirement is not met as evidenced by:
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The Executive Director shall review the Health and Safety Code 1568.683 on Evictions. A letter to rescind the eviction letter served on 7/9/21 shall be provided to R1 and verification to LPA by POC due date 8/18/21.
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The licensee did not ensure that the reasons for eviction for R1 was written on the eviction letter which poses a potential health, safety, and personal right risk to resident in care.
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Type B
08/18/2021
Section Cited
CCR
87463(a)
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87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
This requirement is not met as evidenced by:
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The Executive Director shall update R1's Appraisal/Needs and Services Plan to indicate the behaviors which caused for the eviction. The Plan shall be submitted to LPA by POC due date 8/18/21.
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The licensee did not ensure that the Appraisal/Needs and Services Plan for R1 has been updated to address current behaviors which poses a potential health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3