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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/17/2023
Date Signed: 08/17/2023 02:17:10 PM

Substantiated


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
10/18/2022 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221018150130
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:
08/17/2023
UNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Alexander Solorio - Assistant AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility does not have sufficient night staff to meet the needs of the resident in care.
Resident was left for an extended period of time soiled in urine and vomit.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced follow up visit to this facility to assist Licensing Program Analyst (LPA) Joe Katrdzhyan with delivering findings on the above-mentioned allegations. LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit.

LPA Katrdzhyan conducted prior visits to this facility on 10/24/22, 6/29/23 and 7/24/23, in reference to the above-mentioned allegations. During the course of the investigation, interviews were conducted with various persons to include the Assistant Administrator, Staff 1 (S1) and Residents 1 – 8 (R1 – R8). LPA was unable to interview S2 as S2 no longer works for the facility and her whereabouts are unknown at this time. Also, copies of the following documents were obtained and reviewed in reference R1: Resident Face Sheet, Physician's Report, Functional Capability Assessment, Preplacement Appraisal Information, Resident Appraisal, Appraisal/Needs and Services Plan, Admission Agreement and Resident Roster.

(Continued to LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
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 5
Control Number 28-AS-20221018150130
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: 08/17/2023
NARRATIVE
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The investigation revealed the following:

Allegations: Facility does not have sufficient night staff to meet the needs of the resident in care & Resident was left for an extended period of time soiled in urine and vomit. The details of these allegations stated that, since 10/07/22, there has been inadequate overnight caregiver coverage, which has led to several hours of a resident laying in bed soiled in urine and sometimes in vomit. Also, residents diapers and soiled beddings are not changed for up 6 hours during the overnight shift. Based on interviews conducted, the statements obtained were consistent and corroborated with the above-mentioned allegations. Interviews conducted confirmed that during the month of October 2022, Staff 2 (S2) was a “no-show” multiple times, leaving only one caregiver on duty during the overnight shift, between the hours of 10:30pm – 6:30am. Statements obtained confirmed that overnight staff were observed in the office area most of the time, sitting or sleeping and not doing rounds every two hours and checking on the residents. It was reported that overnight staff would at times ignore the residents call for help and when staff did respond, residents waited 2 or more hours before receiving assistance. Statements obtained from residents and staff corroborated that caregivers were not doing diaper changes during the overnight shift and/or changing soiled resident beddings and morning staff would often times find incontinent residents laying in bed, wet and soiled for hours. Based on the investigation conducted, there was sufficient evidence found, proving the above-mentioned allegations to be true.

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: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/18/2022 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221018150130

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:
08/17/2023
UNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Alexander Solorio - Assistant AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff are not meeting resident's hygiene needs while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced follow up visit to this facility to assist Licensing Program Analyst (LPA) Joe Katrdzhyan with delivering findings on the above-mentioned allegations. LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit.

LPA Katrdzhyan conducted prior visits to this facility on 10/24/22, 6/29/23 and 7/24/23, in reference to the above-mentioned allegation. During the course of the investigation, interviews were conducted with various persons to include the Assistant Administrator, Staff 1 (S1) and Residents 1 – 8 (R1 – R8). LPA was unable to interview S2 as S2 no longer works for the facility and her whereabouts are unknown at this time. Also, copies of the following documents were obtained and reviewed in reference R1: Resident Face Sheet, Physician's Report, Functional Capability Assessment, Preplacement Appraisal Information, Resident Appraisal, Appraisal/Needs and Services Plan, Admission Agreement and Resident Roster.

(Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20221018150130
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: 08/17/2023
NARRATIVE
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The investigation revealed the following;

Allegation: Facility staff are not meeting resident's hygiene needs while in care.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. Staff and residents interviewed stated that residents are given showers twice a week or as needed. Residents on hospice will normally receive three to four showers per week. Residents on hospice will receive showers twice by the hospice agency and once or twice by the facility staff, depending on resident needs. If a resident has an accident or requests an additional shower, staff will accommodate their request. Staff and residents interviewed denied staff not meeting residents hygiene needs. Residents interviewed did not present any concerns about not receiving or missing showers. Based on the investigation conducted, there is insufficient evidence to support the above-mentioned allegation to be true.

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.

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: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20221018150130
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2023
Section Cited
CCR
87411(a)
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Personnel Requirements – General.
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
This requirement is not being met as evidenced by:
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Administrator will review Title 22 Regulations Section 87411 on Personnel Requirements – General and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
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Interviews conducted confirmed that during the month of October 2022, Staff 2 (S2) was a “no-show” multiple times, leaving only one caregiver on duty during the overnight shift, between the hours of 10:30pm – 6:30am. Statements obtained confirmed that overnight staff were observed in the office area most of the time, sitting or sleeping and not doing rounds every two hours and checking on the residents. It was reported that overnight staff would at times ignore the residents call for help and when staff did respond, residents waited 2 or more hours before receiving assistance. This poses a potential health, safety or personal rights risk to persons in care.
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Type B
08/24/2023
Section Cited
CCR
87625(b)(2-3)
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Managed Incontinence.
In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
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Administrator will review Title 22 Regulations Section 87625 on Managed Incontinence and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
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This requirement is not being met as evidenced by:
Statements obtained from residents and staff corroborated that caregivers were not doing diaper changes during the overnight shift and/or changing soiled resident beddings and morning staff would often times find incontinent residents laying in bed, wet and soiled for hours. 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: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5