198603286-8-25-2023-28-AS-DSIS-CV8QHG-20230831121107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/25/2023
Date Signed: 08/25/2023 02:39:48 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
01/19/2021 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210119112942

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:	08/25/2023
		UNANNOUNCED	TIME BEGAN:	08:31 AM
MET WITH:	Alex Solorio - Assistant Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility is not kept clean.
Facility does not have an adequate supply of hygiene items.
Facility staff were not notified of resident's dietary restrictions.
Facility staff are not keeping accurate resident records.
Facility is not providing residents with a good quantity of food.
Facility is not providing residents with a good quality of food.
Facility staff are not properly trained.
Facility staff are not using universal precautions when changing resident's diapers.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit investigate the above allegations. Upon arriving at the facility, LPA met with Assistant Administrator - Alex Solorio and the purpose of today’s visit was explained.

The investigation consisted of the following:
LPA Joe Katrdzhyan conducted the initial complaint investigation on 01/28/2021 for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the investigation was conducted telephonically and due to insufficient information available at the time further investigation was needed.
LPA Tena Herrera conducted a subsequent on 8/24/23. LPA obtained a copy of the Staff/Resident rosters, suggestion form and the food menu, toured the facility with Staff #1, interviewed Staff #1 to #8, reviewed 11
(Continued on 9099-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: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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-20210119112942

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: 08/25/2023

NARRATIVE

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resident files and 4 staff files. Due to time constraints and insufficient information available at the time investigation further investigation was needed.
During todays subsequent on 8/25/23 visit LPA interviewed 8 Residents and reviewed 6 Staff files.

The investigation revealed the following:

Allegation: Facility is not kept clean.
It is alleged that the facility "was not clean in any sense", there is no staff assigned with cleaning the facility, all trash cans were overflowing, and "all the rooms are not kept well in any way".
During the tour of the facility LPA entered 10 rooms and all trash cans in rooms and restrooms visited were observed to be empty or with little trash. The housekeepers were making there rounds while tour was conducted and LPA observed them to be emptying the trash cans, sweeping, and cleaning the restrooms. Rooms appeared to be clean and sanitary. LPA reviewed the housekeeping schedule and there is an itinerary with assigned cleaning duties throughout the day/week. LPA conducted 8 staff interviews, 8 out of 8 staff stated that the facility is cleaned regularly and there are housekeepers assigned with cleaning duties. LPA conducted 8 resident interviews, 7 out of 8 residents denied the above allegation and stated that the facility is cleaned regularly and their trash is taken out 2 times a day.

Allegation: Facility does not have an adequate supply of hygiene items.
It is alleged that there was no toilet paper available for the residents.
During tour of the facility LPA observed 10 resident restrooms and saw that there was sufficient amount of toilet paper readily available for residents, there was one on the spool along with one more roll on counter in each of the restrooms. LPA observed housekeepers while cleaning restroom and saw that the toilet paper was being replenished during their rounds. LPA checked the stock room for supply of toiletries and there was a sufficient amount available. Interviews conducted with staff revealed that residents are able to ask for toilet paper if they run out or are low and a surplus stock is kept at front office in the case that a resident is in need. LPA interviewed residents 8 out of 8 residents deny the above allegation and stated that they always have sufficient supply of toiletries and if they are ever in need they ask housekeeping or front staff for more and it is provided to them without any issues.
(Continued on 9099-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210119112942

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: 08/25/2023

NARRATIVE

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Allegation: Facility staff were not notified of resident's dietary restrictions.
It is alleged that when staff passed out food for breakfast and lunch, they were not made aware of any of the resident's allergies or food restrictions.
During facility tour LPA observed the kitchen and list of individuals with special diets or allergies was posted on a pegboard. This list had a photo of the individual, along with name and what their dietary restrictions are. LPA observed the foods prepared for the individuals with these special diets and they are individually wrapped with their names on the plates, LPA asked kitchen staff and staff assisting with serving meals if they knew who these meals go to and each were able to identify the correct resident. During interviews with staff who work in the kitchen 2 out of 2 staff stated that they are aware of the residents who are on special diets and prepare the meals to meet the needs of their doctors orders, interviews also revealed that staff are trained on which residents have food restrictions and information is posted within the kitchen for all employees who assist in serving to see. LPA interviewed 8 residents of the 8 residents 2 were on special diets and stated that they do get their meals that meet their doctors orders and meals come wrapped with their names on it.
Allegation: Facility staff are not keeping accurate resident records.
It is alleged that facility staff are not accurately updating residents’ files and that "no one documents anything".
LPA reviewed 11 resident files, 11 out of 11 files reviewed were up to date with Physician Reports that were updated yearly. The initial appraisals were in each file with reappraisals for the individuals who have had a change in condition. During interviews with staff 2 out of 8 staff update resident files and both stated that the Physicians Reports are updated yearly and there is a calendar that has a reminder of which resident is due for their yearly assessment. Although most residents at the facility are independent, the facility does try to upkeep their files with any doctor visits the residents schedule themselves with. However, sometimes that information is not given to the facility, therefore, to ensure the residents needs are being met the facility has Physician Reports updated annually.
Allegations: Facility is not providing residents with a good quantity and quality of food.
It is alleged that the residents are not provided with an adequate amount of food.
LPA toured kitchen and food supply for perishables and nonperishable was sufficient to meet the needs of the residents. During tour LPA observed the meal served for the day and lunch consisted of rice, vegetables, chicken, garlic bread and 3 drink choices. LPA observed the weekly/monthly food menu and alternative food menu and all seemed to have a variety of foods and deserts. LPA interviewed 8 residents, 8 out of 8 residents denied the allegation and stated that although the food could be of better taste to accommodate(Continued on 9099-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20210119112942

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: 08/25/2023

NARRATIVE

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their personal preference they feel the food is decent and are given seconds when asked. Residents also stated that snacks are provided 2 times a day or when they ask.

Allegation: Facility staff are not properly trained.

It is alleged that staff does not appear to be properly trained as they do not appear to be comfortable when changing resident's diapers.
LPA reviewed 6 staff files, 6 out of 6 files had the staffs initial training documented along with continuous training that's done yearly. Within the training for the caregivers that provide assistance with incontinence care there is a section covered that is specific with assisting the resident with toileting. LPA conducted 8 staff interviews, 4 out of the 8 staff assist residents directly and confirmed that they are provided training at hire, yearly and there are several in house training's conducted regularly. LPA interviewed 8 residents and 7 out of 8 residents denied the above allegation and stated that they feel the staff that assist them are properly trained and seem to know how to handle residents properly. Of the 8 residents 2 confirmed they have incontinence care and feel comfortable with the staff that assist with changing and feel they are trained and professional when doing so.

Allegation: Facility staff are not using universal precautions when changing resident's diapers.
It is alleged that staff is not changing gloves or washing hands after changing resident's diapers.
During tour LPA observed sufficient supply of gloves for staff. LPA interviewed staff 3 out of 8 staff either assist with incontinence care or are trained to be able to assist all 3 staff stated that their procedure when assisting with incontinence care they first put on gloves (some double glove) and when finished assisting they dispose of gloves immediately, wash hands and put on a new pair if other care is needed. Staff stated that they never use the same pair of gloves on multiple residents. Upon interviewing residents with incontinence care 2 out of 2 residents confirmed that the staff switch out their gloves after care is provided. Upon reviewing the training on toileting, staff are trained to use a new pair of gloves before assisting resident and dispose gloves, then wash hands after care is provided.

Based on statements and interviews conducted with staff and residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview held, and a copy of this report was provided to Assistant Administrator Alex Solorio.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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