198603286-5-4-2023-28-AS-FFIS-CW9URQ-20231003154908

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:23:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/24/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230424090141

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: 77	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Assistant Administartor -Alexander 'Alex' Solario		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Staff failed to provide a safe and comfortable environment for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander Solorio (Assistant Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters, Special Incident Reports, Resident #1 (R1) and Resident #2 (R2) : Physican Report, Pre-Placement Apprasial and Apprasial Needs and Service Plan.R2's Behavior Contract, R2's Relocation, Meeting Notes with Case Manager regarding R1 and R2, R1 and Resident #3 (R3) room change refusal, R2's House Rule Agreement, R1 Court Hearing Documents towards R2. LPA Intervierw Assistant Administrator Alexander Solario, Staff #1,#2 and #3 (S1,S2,S3), LPA Interviewed R2's Case Manager and R2's Program Manager and interviewed residents: R1 and R3 , attempt to interview via telephone R2 and Resident #4- Resident #8 (R4, R5, R6,R7) and R8).

Continuatuion on LIC 9099-D...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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-20230424090141

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA VILLA SENIOR LIVING	FACILITY NUMBER: 198603286
	VISIT DATE: 05/04/2023

NARRATIVE

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Regarding allegation: Staff failed to provide a safe and comfortable environment for resident. LPA Calderon interview Assistant Administrator Alex, Staff #1- Staff #3 all denied the above allegation. Alexander and S1 stated to provide a comfortable and safe environment they were having meetings with the case manager to address issues with R1 and R2. S2 and S3 during interviews stated front office staff let us know about issues with R1 and R2 and we would increase supervision and do more rounds and were aware of issues occurring and facility was addressing the situation for residents to feel safe and comfortable. LPA Calderon interviewed Case Manager for R2 and stated Alex would communicate to discuss a plan for residents to be safe/comfortable and meetings were addressed to work on issues for residents. LPA interview with Program Manager stated Alex did have plan for residents to be in a safe and comfortable environment. LPA Calderon interviewed Residents: R3, R4-R7 all denied the above allegation and stated they feel safe and comfortable with the facilities environment, and staff assist when needed. LPA reviewed Special Incident Reports and Meeting Notes with Case Manager all indicated that Case Manager was involved and that facility was taking action for residents to be redirected when issues arised to provide a safe/ comfortable environment.

Although the allegation 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 was conducted and a copy of today's report was provided to Alexander Solario, Assistant Administrator.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

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