198603286-8-3-2023-28-AS-DSIS-CUH26Z-20230807170755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/03/2023
Date Signed: 08/03/2023 04:08:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/06/2023 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230306123319

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: 76	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	11:47 AM
MET WITH:	Alex Solorio - Assistant Administrator		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Facility staff did not prevent resident from being assaulted by another resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegation of "Facility staff did not prevent resident from being assaulted by another resident while in care". LPA met with Assistant Administrator Alex Solorio and the purpose for the visit was explained.

The investigation consisted of the following: LPA Kruz Long conducted a prior visit to this facility on 3/14/23 and obtained/reviewed a copy of the Staff/Resident rosters, Physician's Report and Appraisal Needs and Services Plan for Resident #1 and #2 (R1 and R2), Incident report and food menu, toured the kitchen with Staff #1, interviewed Staff #1 to #6 (S1-S6) in the office and interviewed R1-R7 in various locations of the facility.
During subsequent visit conducted today 8/3/23 LPA Tena Herrera obtained a copy of the Staff/Resident
Rosters, Behavior Contract for R2, Incident Report, Physician's Report and Appraisal Needs and Services
(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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-20230306123319

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 08/03/2023

NARRATIVE

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Plan for R1 and R2. LPA interviewed S1, S3, S6-S8 and R8-R12.

The investigation revealed the following:
Allegation: Facility staff did not prevent resident from being assaulted by another resident while in care. It is alleged that R1 was attacked by R2 and suffered minor injuries that were treated by paramedics. R1 pressed charges and R2 was issued a misdemeanor citation by the police. LPA interviewed 5 residents during todays visit and 5 out of 5 residents all deny the above allegation. Each stated that the staff do what they can and try their best to de-escalate aggressive situations. Interviews also revealed that staff try best efforts to arrive promptly to the altercation and take immediate action. During staff interviews 5 out of 5 staff stated that when an altercation between residents occur they take immediate action and try to de-escalate the situation. Staff carry walkie-talkies with them so when a situation occurs support staff is alerted immediately to assist. There are usually 3 staff members that work the altercation with best efforts to calm residents and separate them from one another. Depending on the seriousness of the alteration 911 or the non-emergency police telephone line is called. Medical attention is always suggested yet usually refused by the residents involved. Although it is confirmed that R2 assaulted R1, the facility took the proper steps to address the situation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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.

Exit interview held with Assistant Administrator Alexander Solorio and a copy of this report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

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