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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 06/28/2023
Date Signed: 06/28/2023 03:40:55 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
10/14/2022 and conducted by Evaluator Joe Katrdzhyan
COMPLAINT CONTROL NUMBER: 28-AS-20221014123935
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: 73DATE:
06/28/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Resident Care Director / Maria “Luisa” RazoTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not prevent a physical altercation between residents in car

Staff illegally evicted resident

Resident not treated with dignity by staff
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 allegations of "Staff did not prevent a physical altercation between residents in care, Staff illegally evicted resident and Resident not treated with dignity by staff”. Upon arriving at the facility, LPA met with Resident Care Director / Maria “Luisa” Razo who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 10/21/22, in reference to the allegations listed above. During the course of the investigation, interviews were conducted of various persons to include the Assistant Administrator / Alexander Solorio, Resident Care Director / Maria “Luisa” Razo, Business Office Director / Kevin Arutyunyan and Residents 1 - 3 (R1 - R3). LPA was unable to interview Staff 1 (S1) as S1 no longer works at the facility and his whereabouts are unknown at this time. During the initial visit conducted on 10/21/22, LPA reviewed surveillance video of the incident involving R1 and R2. Also copies of the following documents were obtained and reviewed;
• Resident Roster • Facility House Rules • 30 Day Termination Notices for R1 and R2 • Unusual Incident/
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
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-20221014123935
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: 06/28/2023
NARRATIVE
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Injury Reports involving R1, R2 and R3.

The investigation revealed the following;

Allegation: Staff did not prevent a physical altercation between residents in care. The details of this allegation states that R1 was involved in two separate incidents, involving two separate residents. The first alleged incident involves R2 and it is alleged that R2 slapped R1 on the left side of her face and pulled her hair. The second alleged incident involves R3 and it is alleged that R3 cut R1 with his fingernails.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. According to the surveillance video, on 10/9/22, at approximately 9:58pm, S1 is observed escorting R1 back to her room (in her wheelchair), after her shower. At the same time, R2 is observed coming in the direction of R1 (from the opposite side) in her wheelchair, to the left of R1. There is also a third resident observed coming in the direction of R1 (from the opposite side) in his wheelchair, to the right of R1. S1 is observed pushing the wheelchair of R1 through the middle of both residents at which time R2 is observed reaching over with her right hand and pulling the hair of R1. S1 is observed immediately intervening and breaking up the incident and separating both residents. After the incident, S1 is observed continuing to escort R1 back to her room. Interviews conducted of staff and R1 and R2 stated that there is nothing different that S1 could have done to prevent R2 from reaching over and pulling the hair of R1. This was an unexpected incident. In the Surveillance video, R2 does not slap R1. During the interview of R1, R1 denied R2 slapping her on the left side of her face. R1 and R2 did not sustain injuries as a result of this incident. The Pasadena Police Department was involved and spoke with both residents involved and no arrests were made. Although it appears an altercation did occur between R1 and R2, staff intervened immediately, applied first aid, 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.
On 10/18/22, there was an incident at the outside patio smoking area involving R1 and R3, where R1 sustained a scratch on her arm (unknown which arm). During the interview of R1, R1 stated that "R3 got too close to me and I pushed him back and he cut me". During the interview of R3, R3 denied hurting R1 intentionally and stated that he was having a conversation with R1 because R1 had accused him of bringing alcohol inside the facility (which he strongly denied), and during the conversation with R1, R1 became upset and tried to strike R3. As R1 was attempting to strike R3, R3 grabbed the arm of R1 to prevent R1 from striking him, causing a scratch on the arm of R1. According to both residents, there were no witnesses to this incident. Staff was notified after the incident and applied first aid to the arm of R1. Interviews conducted of
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20221014123935
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: 06/28/2023
NARRATIVE
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R1 and R3 stated that there is nothing different that staff could have done to prevent this incident from happening. R1 and R3 and independent and do not require one to one supervision. Although it appears an altercation did occur between R1 and R3, staff applied first aid after learning of the incident and asked both residents to stay away from each other. 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.

Allegation: Staff illegally evicted resident. The details of this allegation states that R1 is being illegally evicted. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. After reviewing the file of R1 and conducting interviews of staff, LPA discovered that R1 was issued a 30 Day Eviction Notice on 10/20/22, for breaking facility house rules and failing to pay rent. During the period of 9/1/22 - 10/20/22, R1 was observed violating house rules by being verbally and physically abusive towards staff and other residents. Additionally there was possession of an illegal substance found inside her room on 9/7/22. R1 also stopped paying rent and had an outstanding balance of $1,620.46 owed to the facility. Based on the information gathered, there is insufficient evidence to support the above allegation to be true.

Allegation: Resident not treated with dignity by staff. The details of this allegation states that R1 was involved in a verbal altercation with the Business Office Director and was treated in an antagonizing manner.
On 10/20/22, the Assistant Administrator, along with the Business Office Director went to R1's room to hand deliver the 30 Day Eviction Notice. After handing the eviction notice to R1 and explaining the purpose of why it was issued, R1 began screaming and using profanity towards the Assistant Administrator and the Business Office Director. R1 also threatened by stating that if they did not leave her room, she would strip naked and claim that they were assaulting her. During the interview of the Business Office Director, he denied speaking to R1 in an antagonizing manner. During the interview of the Assistant Administrator, it was stated that R1 was verbally abusive during the incident and threatened him and the Business Office Director. The Assistant Administrator denied the Business Office Director speaking to R1 in an antagonizing manner. There were no other witnesses present at the time of the incident. Based on the information gathered, there is insufficient evidence to support the above allegation to be true.

Although the allegations 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.
An exit interview was conducted and a copy of this report was provided to the Resident Care Director.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3