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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/25/2023
Date Signed: 07/25/2023 03:08:13 PM

Substantiated


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
10/10/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221010164936
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: 76DATE:
07/25/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not treat residents with dignity or respect.

Insufficient staff meeting the qualifications and competency to meet residents' care needs.
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 treat residents with dignity or respect and Insufficient staff meeting the qualifications and competency to meet residents' care needs”. 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 10/20/22, 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, Staff members 1 through 3 (S1 – S3) and Residents 1 through 5 (R1 – R5). Also, copies of the following documents were obtained and reviewed;
• Resident Roster • Personnel Report • CPR/AED/First Aid Certificate for Staff 4 (S4) • Food Handler Certificate of Completion for S4 • New Hire Initial Training Record for S4 dated: 7/22/20 • Hands on Training Record for period 7/29/20 - 8/12/20 for S4.
Substantiated
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: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
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 8
Control Number 28-AS-20221010164936
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: 07/25/2023
NARRATIVE
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The investigation revealed the following;

Allegation: Staff did not treat residents with dignity or respect. The details of this allegation states that on 9/7/22, at approximately 12:40pm, S1 started shouting at R1 at the top of her voice while sitting inside the office, which was approximately 30 feet away from where R1 was standing. S1 shouted in Spanish and the tone she used was humiliating and intimidating towards R1.
Based on interviews conducted, the statements obtained were consistent and corroborated with the above-mentioned allegation. The alleged incident happened on 9/7/22, at approximately 12:40pm. R1 was standing in the hallway, near the office and was overheard yelling “bano” repeatedly, indicating he wanted a shower. S1 was on her break sitting inside the office, approximately 30 feet away from R1 and instead of getting up to address R1 that she was on break, S1 began yelling at R1 in Spanish, stating that “I’m on my break right now, I will shower you”. There were multiple witnesses who observed the incident and stated that S1 was observed yelling at R1 in a humiliating and intimidating manner and could have addressed the situation differently by getting up and explaining to R1 that she was on her break and would assist him with his shower upon returning from break. Based on the investigation conducted, there was sufficient evidence found, proving the above-mentioned allegation to be true.

Allegation: Insufficient staff meeting the qualifications and competency to meet residents' care needs. The details of this allegation states that on 9/7/22, at approximately 12:40pm, a witness observed that there were two caregivers on shift, one of whom was S1 and S1 was on break at the time. When the witness inquired with S3 if that meant that there is currently only one caregiver on the floor, S3 stated that "there are two kitchen staff who help too”. S3 was asked if that meant that kitchen staff were assisting with resident care needs, S3 replied “yes”.
Based on interviews conducted, the statements obtained were consistent and corroborated with the above-mentioned allegation. Statements obtained from staff and residents stated that S4, who works in the kitchen, will often times assist residents with care. After reviewing the file of S4, LPA observed that S4 does not have the required training to provide resident care, such as assisting with showers, changing and providing incontinence care. Also, S4’s CPR/First Aid Certificate had expired on April 30, 2022. Based on the investigation conducted, there was sufficient evidence found, proving the above-mentioned allegation to be true.

(Please see LIC 9099C for additional information)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 28-AS-20221010164936
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: 07/25/2023
NARRATIVE
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Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.


An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 28-AS-20221010164936
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: 07/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2023
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities.
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Administrator will review Title 22 Regulations, Section 87468.1 on Personal Rights, and conduct an in-service training with all staff on the importance of resident personal rights. Administrator will submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training to CCL,
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This requirement is not being met as evidenced by:
On 9/7/22, at approximately 12:40pm, S1 was overheard by witnesses yelling at R1 in a humiliating and intimidating manner. This poses a potential health, safety or personal rights risk to persons in care.
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by the POC due date.
Type B
08/08/2023
Section Cited
CCR
87411(c)
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Personnel Requirements – General
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.
This requirement is not being met as evidenced by:
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The Administrator will provide training to S1 with the required training and submit proof of training record; training topic, date, time, training duration, along with signature of S1 to CCL, by the POC due date.
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Statements obtained from staff and residents stated that S4, who works in the kitchen, will often times assist residents with care. After reviewing the file of S4, LPA observed that S4 does not have the required training to provide resident care, such as assisting with showers, changing and providing incontinence care. This poses a potential health, safety or personal rights risk to persons 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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 28-AS-20221010164936
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: 07/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2023
Section Cited
CCR
87411(c)(1)
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Personnel Requirements – General
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not being met as evidenced by:
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The Administrator will ensure that S1 has a current First Aid Certificate and submit current documentation to CCL by POC due date.
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During the visit conducted on 10/20/22, LPA reviewed the file of S1 and observed that the CPR/First Aid Certificate for S1 expired on April 30, 2022. This poses a potential health, safety or personal rights risk to persons 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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
10/10/2022 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221010164936

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: 76DATE:
07/25/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not respond to residents call for assistance in a timely manner.

Facility is unsanitary.
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 respond to residents call for assistance in a timely manner and Facility is unsanitary”. 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 10/20/22, 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, Staff members 1 through 3 (S1 – S3) and Residents 1 through 5 (R1 – R5). During the visit conducted on 10/20/22, LPA toured the facility (physical plant / inside only).

(Please see LIC 9099C for additional information)
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: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 28-AS-20221010164936
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: 07/25/2023
NARRATIVE
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The investigation revealed the following;

Allegation: Staff did not respond to residents call for assistance in a timely manner. The details of this allegation states that R1 called out from the hallway "bano" repeatedly, indicating they required assistance with bathing. Despite this, no staff members came to assist him.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. The alleged incident happened on 9/7/22, at approximately 12:40pm. R1 was standing in the hallway, near the office and was overheard yelling “bano” repeatedly, indicating he wanted a shower. According to staff, R1 receives showers from the hospice nurse twice a week. R1 was not scheduled for a shower on 9/7/22 but staff told R1 that they would assist him with his shower once they were done giving showers to the residents on schedule for that day. At the time of the alleged incident, there were two caregivers working. One of the caregivers was on break. The Med Tech was assisting with passing out medications and the Activities Director and the Assistant Administrator were also on duty assisting other residents with care. Statements obtained from residents denied staff not responding to residents call for assistance in a timely manner. Based on the information gathered, there was insufficient evidence found regarding the above-mentioned allegation.

Allegation: Facility is unsanitary. The details of this allegation states that on 9/7/22, between 12:40pm and 1:10pm, discarded plates of food were observed in the hallways and on the floor, as well as discarded soiled clothes.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. Statements obtained from staff stated that the only time empty plates of food can be found on the floors are after lunch as some of the residents have a habit of placing their empty plates on the floors, in front of their rooms so that staff can pick them up. Some residents also leave their dirty/soiled clothes on the floors, in front of their rooms so that staff can pick them up for laundry. Staff remind residents who tend to leave their plates on the floors to leave the plates in their rooms for staff to pick up but residents continue to leave them on the floors. Staff also remind residents not to leave dirty/soiled clothes on the floors and to call staff for assistance in picking up their dirty clothes for laundry. Residents interviewed stated that staff are quick to pick up empty plates from hallway floors after lunch and denied seeing dirty/soiled clothes in the hallways. During the visit conducted on 10/20/22, LPA toured the facility (physical plant / inside only) in the AM and also in the PM and did not observe discarded plates of food or soiled clothes on the hallway floors. Based on the information gathered, there was insufficient evidence
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 28-AS-20221010164936
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: 07/25/2023
NARRATIVE
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found regarding the above-mentioned allegation.

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 Assistant Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8