198603286-8-25-2023-28-AS-RORN-CV6QZF-20230829123637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/25/2023
Date Signed: 08/25/2023 02:38:01 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
10/28/2022 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221028165455

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:	10:50 AM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	02:42 PM

ALLEGATION(S):

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Staff left resident soiled for an extended period of time.
Staff do not provide quality food to residents.
Staff do not assist with resident's showering needs.
Staff do not provide resident with clean clothing.
Staff do not provide resident with clean linen.
Resident's call button is in disrepair.
Staff do not respond to resident's call button.
Resident's urine container is not properly disposed.
Staff do not treat resident with dignity or respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 11/03/2022, LPA obtained copies of staff & resident rosters, interviewed Assistant Administrator, Resident 2 - Resident 7 (R2-R7) and toured the facility kitchen and R1-R7 bedrooms. Resident 1 (R1) was admitted at a hospital on 10/18/22 and was not available for an interview. LPA also requested R1's admission agreement, appraisal/needs and service plan, pre-appraisal, physician report, functional capability assessment, resident appraisal and a copy of a text message regarding R1. During today's visit, LPA toured the kitchen, facility and 3 resident bedrooms, and interviewed Staff 2 - Staff 3 (S2 - S3). During today's visit, LPA was informed that R1 no longer resides at this facility as of 11/24/2022 and S1 is no longer working at this facility as of 03/06/2023.
(Continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
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-20221028165455

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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The investigation revealed the following:

Regarding the allegation "staff left resident soiled for an extended period of time", it is alleged that on 09/06/2022, R1 had a bowel movement and requested assistance from S1 to get changed, but S1 refused to assist R1 and R1 had to wait until 2am to be changed by S2. Assistant Administrator stated this incident was never brought up to his attention by R1. S2 denied the allegation. Residents interviewed could not corroborate the allegation. There were 3 residents that stated they have never soiled themselves, but believed that staff would provide timely assistance. The other 3 residents stated that they have soiled themselves in the past and staff provided timely assistance.

Regarding the allegation "staff do not provide quality food to residents", it is alleged that the food at the facility tastes and looks like cat food. Facility denied the allegation and stated they follow a dietician's recipe to prepare good quality food. Residents interviewed could not corroborate the allegation. During the tour of the kitchen on 11/03/2022 and today, LPA observed that the food had good presentation.

Regarding the allegation "staff do not assist with resident's showering needs", it is alleged that R1 did not received the scheduled shower on 09/02/2022. Assistant Administrator stated that R1 did not received his scheduled shower on that day because R1 was not at the facility. There is text message dated 09/04/2023 between Assistant Administrator and a staff where the staff texted the Assistant Administrator that R1 was not in the facility on 09/02/2022. Residents interviewed could not corroborate the allegation and expressed no concerns.

Regarding the allegation "staff do not provide resident with clean clothing", it is alleged that R1 is not getting assistance with changing clothes. Assistant Administrator and staff denied the allegation. They stated that R1 was offered a change of clothes every morning. Residents interviewed could not corroborate the allegation and expressed no concerns.

Regarding the allegation "staff do not provide resident with clean linen", it is alleged that R1's bed sheets are supposed to be changed twice per week, however that does not happen. Assistant Administrator and staff denied the allegation and stated that bed sheets are changed once a week or as needed. Residents interviewed could not corroborate the allegation and expressed no concerns.
(Continued to LIC 9099-C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
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-20221028165455

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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Regarding the allegations "resident's call button is in disrepair" and "staff do not respond to resident's call button, it is alleged that R1's call light button either does not work or staff do not respond. Assistant Administrator and staff interviewed stated that R1 did not report any issues with the call light button. They also stated that staff do respond to all call light request in a timely manner, usually within 10 minutes. Residents interviewed could not corroborate the allegation and stated that staff show up quickly, right away or within 10 minutes.

Regarding the allegation "resident's urine container is not properly disposed", it is alleged that R1's urinal container on the side of resident's bed is not emptied in a timely manner. Assistant Administrator and staff denied the allegation and stated that those containers are emptied as needed. Facility does not have many residents that use a urine container. During the 11/03/2022 visit, LPA interviewed 2 residents that use it and they expressed no concerns, and observed that their urine containers were empty and cleaned. During today's visit, LPA walked into 3 resident bedrooms that use the urine containers and observed that the containers were emptied and cleaned.

Regarding the allegation "staff do not treat resident with dignity or respect", it is alleged that when R1 request for assistance with care and housekeeping duties, the staff respond with an attitude. Staff denied the allegation and stated that all residents are treated with respect. Residents interviewed could not corroborate the allegation and expressed no concerns.

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 the report was provided

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
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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