198603286-12-14-2021-28-AS-RORN-CU4NDP-20230726102238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 12/14/2021
Date Signed: 12/14/2021 04:16:32 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: 43	DATE:	12/14/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Assistant Administrator / Alexander Solorio		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff did not prevent residents from engaging in a physical 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 "Facility staff did not prevent residents from engaging in a physical altercation". Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 10/27/21, in reference to the allegation listed above. During the course of the investigation, LPA conducted interviews of various persons to include the Assistant Administrator, Staff members 1 - 3 (S1 - S3) and Residents 1 - 4 (R1 - R4). LPA also reviewed the surveillance video regarding the incident involving Residents 1 and 2 (R1) and (R2).

The investigation revealed the following;
The incident involving R1 and R2 occurred on 10/20/21, at approximately 2:30pm. Based on interviews conducted, R2, who is visually impaired was observed by witnesses yelling in the lobby, near her room.

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: 12/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

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-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: 12/14/2021

NARRATIVE

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R1, who resides a couple of doors down from R2 was observed by witnesses coming out of her room (in her wheelchair) telling R2 that there is no one in the lobby and to stop yelling. According to witnesses, the incident escalates quickly and that is when R2 approaches R1 and slaps R1 in the face. Based on interviews conducted, the majority of the statements obtained stated that the incident could not have been prevented by staff. S1, who is the facility housekeeper observed the verbal exchange between R1 and R2 and before he was able to walk over and notify staff, R2 approached R1 and slapped R1 in the face. R1 did not sustain and injuries as a result of the incident. R1 still resides at this facility. R2 no longer resides at this facility as R2's placement agency (DHS) transferred R2 to another facility on 12/6/21. During the visit conducted on 10/27/21, LPA reviewed the surveillance footage of the incident involving R1 and R2 with the assistance of the Assistance Administrator. Based on LPA’s observations, the incident took about one minute and thirty seconds from the time the two residents were observed exchanging words in the hallway leading to R2 slapping R1. In the video, R2 is observed in the hallway by herself, standing in front of her room (with her back facing the camera). A few seconds later R1 is observed coming out of her room in her wheelchair and both residents are then observed exchanging words. S1 (Housekeeper) is observed arriving at the scene and assessing the situation and as the two residents are getting loud, S1 is observed walking away to inform staff about the two residents arguing. As S1 is observed walking away, R2 is observed walking towards R1 (while R1 is sitting in her wheelchair) and R2 slaps R1 in the face. Shortly after staff is observed arriving at the scene to de-escalate the situation. Based on LPA's observations and interviews conducted, the incident involving R1 and R2 escalated quickly and there was insufficient time for staff to intervene and prevent the incident from happening.

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: 12/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021

LIC9099 (FAS) - (06/04)

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