198603286-7-24-2023-28-AS-RORN-CU4NDN-20230726102237

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 05/16/2023
Date Signed: 07/24/2023 01:55:21 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
10/21/2021 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211021085901

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: 74	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Assistant Administrator / Alexander Solorio		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is retaining residents who require a higher level of care

INVESTIGATION FINDINGS:

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

***This is an amended report which supersedes the original report dated 5/16/23. The purpose of this report is to remove confidential information in reference to Residents 1 and 2. The amendments to the report do not affect or change the findings on this complaint.***

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Facility is retaining residents who require a higher level of care." Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit.

LPA Katrdzhyan conducted prior visits to this facility on 10/27/21 and 12/14/21, in reference to the allegation listed above. During the course of the investigation, LPA interviewed the Assistant Administrator and Staff members 1 - 3 (S1 - S3). LPA reviewed and obtained copies of resident files in reference to Residents 1 and 2 (R1 and R2).

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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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-20211021085901

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: 05/16/2023

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

The investigation revealed the following;
Allegation: Facility is retaining residents who require a higher level of care. Based on interviews conducted and record reviews, the statements obtained along with the information collected did not corroborate with the
allegation. According to the Assistant administrator, the majority of residents who were admitted to Pasadena Villa Senior Living around the time of licensure were referrals from Department of Health Services (DHS). A proper assessment was conducted by the Administrator on R1 and R2.

According to the Physician's Report for R1, R1 was listed as unable to bathe self, able to dress/groom self w/minimum assistance, able to feed self, unable to care for own toileting needs and unable to store or administer own medications. In the Preplacement Appraisal for R1 it states; R1 is non-ambulatory, uses a wheelchair, is alert and oriented and R1 likes to stay in room and watch TV. R1 was not listed as someone who needed higher level of care.
According to the Physician's Report for R2, R2 was listed as independent and able to leave facility unassisted. R2 was able to store own medications but needed minimal assistance. According to the notes from DHS, R2 did not require one-on-one supervision. In the Preplacement Appraisal for R2, it states; R2 is visually impaired and uses cane. R2 was described as someone who likes to hear the TV and radio. R2 was not listed as someone who needed higher level of care.

Based on the information gathered, there is insufficient evidence to support this 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 Assistant Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2