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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 09/12/2023
Date Signed: 09/12/2023 01:09:46 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
09/06/2023 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230906112519
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: 74DATE:
09/12/2023
UNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Carinn Mendoza - CaregiverTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Resident call buttons are in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Carin Mendoza, Assistant administrator arrived 5 minutes later and explained the reason of the visit.

The investigation consisted of the following: LPA Flores requested copies of resident/staff roster, conducted a tour of the facility's kitchen, observed 7 resident rooms and tested call buttons in rooms #12,14, and 3. LPA interviewed Residents #1-7(R1-R7) and staff #1-5(S1-S5). LPA requested copies of menu for 4 weeks, physician's report, resident information/care plan, and needs and care plan for 7 residents and incident report dated 8/23/23 and 9/12/23.

The investigation revealed the following: Regarding allegation: Resident call buttons are in disrepair. It is alleged call buttons are broken.
(CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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 6
Control Number 28-AS-20230906112519
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: 09/12/2023
NARRATIVE
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Interviews with 4 out of 7 residents revealed they did not have a call button in their room and were not able to provide a reason to not having one. 3 out of 7 residents interviewed revealed to have a working call button and staff respond to the call button. Interviews with staff revealed residents should or have a call button in their rooms. Interview with assistant administrator revealed that some call buttons have been in disrepair or residents have lost them and the facility is going through the process of repairing/replacing them as they were not aware.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Alexander Solorio Assistant Administrator and a copy of this report, LIC 9099D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
09/06/2023 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230906112519

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: 74DATE:
09/12/2023
UNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Carin Mendoza - Caregiver TIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff are not responding to residents call buttons
Staff are not providing adequate food service to residents
Staff did not prevent resident from engaing in inappropriate behaviors
Staff are not meeting residents needs
Staff are not meeting resident's dietary needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Carin Mendoza, Assistant administrator arrived 5 minutes later and explained the reason of the visit.

The investigation consisted of the following: LPA Flores requested copies of resident/staff roster, conducted a tour of the facility's kitchen, observed 7 resident rooms and tested call buttons in rooms #12,14, and 3. LPA interviewed Residents #1-7(R1-R7) and staff #1-5(S1-S5). LPA requested copies of menu for 4 weeks, physician's report, resident information/care plan, and needs and care plan for 7 residents and incident report dated 8/23/23 and 9/12/23.

The investigation revealed the following: Regarding allegation: Staff are not responding to residents' call buttons. It is alleged that when pressing call buttons nothing happens.
(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20230906112519
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: 09/12/2023
NARRATIVE
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Interviews with 3 out of 7 residents revealed that residents usually scream to call the staff and they do not come right away. 3 out of 7 residents stated that when they use the call button staff come to assist them. 1 out of 7 residents stated to not be able to use the button and prefers to use cellphone and staff do not respond. Interviews with staff revealed staff respond to residents' calls. During the facility tour LPA Flores tested the call buttons in 3 resident rooms. Staff responded to the calls within one minute each time and ask the resident if they can assist them.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegations: Staff are not providing adequate food service to residents and Staff are not meeting resident's dietary needs. It is alleged that the food is substandard and not nutritional and resident who is diabetic was told to make own diabetic menu. Interviews with 5 out of 7 residents revealed facility provides all nutritional items. 2 out of the 5 residents stated even if the food is bad, or does not provide alternatives facility provides a nutritional meal. 2 out of 7 residents interviewed stated the food does not meet nutritional guidelines or facility does not follow special diet guidelines. Interviews with staff revealed kitchen staff follow menus and recipes to prepare meals for all residents and for those with special diets. Staff stated plates are label with residents names for those with special diets. During facility's kitchen tour LPA observed special diet list board and residents needs and care plan posted in the kitchen's wall. Food store in refrigerators and pantry was observed to be a variety of fresh fruits and vegetables, frozen vegetables, proteins,sufficient grains and breads. Document review revealed 2 out of 7 residents had a special diet per physician's report and resident's information/care plan for each note food pref./diet for facility's care to be provided for those two residents. Menus have a variety of food items which provide a protein, a carbohydrate, vegetables/fruits in each meal and an alternative menu sheet is available for residents to choose from.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff did not prevent resident from engaging in inappropriate behaviors. It is alleged resident who was COVID 19 positive was yelling, “Don’t tell me what to do!” while staff were trying to get him to his room and another resident had flip tables in the dining room. (CONTINUED ON LIC 9099C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20230906112519
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: 09/12/2023
NARRATIVE
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Interviews with 2 out of 7 residents revealed staff intervene when they observed residents having behaviors, 2 out of 7 residents stated to not have observed any disruptive behaviors in the facility, 2 out of 7 residents stated behaviors have happened and staff have not stopped it, and 1 out of 7 residents was unable to answer as assistance with care was to be provided at that time. Interviews with staff revealed incident of resident with COVID 19 did occur. However, the resident was being redirected to the room to quarantine. Regarding the other resident flipping the table they stated resident got impatience waiting for the food to be served, however the staff was present and are always around to assist or redirect. Document review revealed on 8/23/23 and incident report was submitted to the department noting incident of resident becoming inpatient and breaking dining room furniture. Facility created has a plan in place for that resident. Incident report dated 9/12/23 address the incident of resident with COVID in which notes staff redirected resident to the room.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.


Regarding allegation: Staff are not meeting residents' needs. It is alleged resident yells for hours for help or water. Interviews with 4 out of 7 residents revealed staff provide assistance when needed and or are meeting their needs. 3 out of 7 residents stated to not being provided assistance when needed and have to wait for hours to be care for. Interviews with staff revealed staff respond promptly to residents calls and or needs and are aware of the residents needs upon admission or returning from the hospital. Assistant administrator stated that for residents with more needs staff have a chart to track every time they are providing care. During facility's tour LPA observed a chart in room #40 which noted on 9/12/22 staff provided water to the resident at 8:00am and 9:17am. Document review revealed each resident has a current needs and service care plan in place.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Alexander Solorio Assistant Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20230906112519
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: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2023
Section Cited
CCR
87303(i)(1)
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87303 Maintenance and Operation: (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more ... buildings shall have a signal system which shall:

This requirement is not met as evidence by:
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Administrator will provide a working call button to each resident and will submit plan to replace or maintain call buttons to the department by POC due date 9/19/23.
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Based on observation and interviews licensee failed to ensure residents had a signal system in place which poses a potential risk to the health, safety, or personal rights to the 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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6