198603286-8-18-2023-28-AS-DSIS-CV8KEG-20230831075015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/18/2023
Date Signed: 08/18/2023 04:28:25 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
05/17/2021 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210517095247

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:	08/18/2023
		UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Alex Solorio - Assistant Administrator		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Facility retaliated against resident for filing a complaint.
Facility staff did not seek medical attention in a timely manner.
Facility staff did not notify resident's authorized representative of a change in resident's condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced follow up visit to deliver findings on the above-mentioned allegations. LPA met with Assistant Administrator Alex Solorio and the purpose for the visit was explained.

The investigation consisted of the following: LPA's Joe Katrdzhyan and Nune Margaryan conducted the initial visit on 5/21/21, however, due to time constraints and insufficient information available at that time, the above allegations needed further investigation. During todays subsequent visit LPA Herrera obtained copys of Staff and Resident Rosters, C1's Records (Face Sheet, Physician's Report, Appraisal Needs and Services Plan, Admission Agreement, Exit Report, Eviction Notice, Relocation Agreement), interviewed Staff 1-6 (S1-S6) and Residents 1-8 (R1-R8).

(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: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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-20210517095247

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: 08/18/2023

NARRATIVE

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The investigation revealed the following:
Allegation: Facility retaliated against resident for filing a complaint.
It is alleged that resident experienced retaliation after filing a complaint through different scenarios that took place thereafter. LPA interviewed 8 residents today and 8 out of 8 residents stated that have not heard of retaliation for filing complaints. Although some feel that some staff could be more kind when dealing with aggressive residents they stated that they haven't experienced retaliation of that sort. LPA's interviews with 6 staff also denied the above allegation and stated that they have not nor have they witnessed another staff retaliate against residents when they file complaints or complain to them personally.

The investigation revealed the following:
Allegation: Facility staff did not seek medical attention in a timely manner.
It is alleged that staff did not seek medical attention in a timely manner for R1 when R1 was found unresponsive by non staff member. It was stated that staff were not "mindful" when asked to call 911. LPA interviewed staff and 5 out of 5 staff stated that when a resident experiences an emergency of that sort, staff will call 911 and a caregiver will stay with resident until paramedics arrive. Staff also stated that rounds are conducted every 2 hours or less depending on the resident needs, some require more frequent checks therefore it may be hourly rounds for those individuals. Interviews with residents, 8 out of 10 residents denied the above allegation and stated that they are given medical attention in a timely manner and see caregivers and staff conducting rounds regularly.

The investigation revealed the following:
Allegation: Facility staff did not notify resident's authorized representative of a change in resident's condition.
It is alleged that R1's responsible party was not contacted when R1 was admitted to the emergency and when responsible party called the staff stated they did not know R1's whereabouts. After file review it was noticed that R1 never had an emergency contact listed and stated responsible party as "self". During interview with S1, staff indicated that R1 never provided an emergency contact and someone did call asking about R1 however, no information could be provided as R1 had not given authorization. S1 stated after this situation they asked R1 if they would like to add an emergency contact but R1 refused. Interviews with residents 8 out of 9 residents denied the above allegation and stated they believe staff will contact responsible party in case of emergencies. Although some residents did confirm they do not have an
(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: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210517095247

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: 08/18/2023

NARRATIVE

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emergency contact listed, therefore, staff would not have anyone to contact. 2 out of the 8 residents that have experienced medical emergencies stated that their responsible parties were contacted with details of their condition.

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 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 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: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC9099 (FAS) - (06/04)

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