198603286-9-14-2023-28-AS-WSHO-CWX995-20231024230947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 09/14/2023
Date Signed: 09/14/2023 02:59:43 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
08/11/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230811103641

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:	09/14/2023
		UNANNOUNCED	TIME BEGAN:	02:54 PM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	03:14 PM

ALLEGATION(S):

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Facility placed resident on hospice without meeting criteria.
Resident is not receiving care as needed.

INVESTIGATION FINDINGS:

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***This report supersedes the report dated 08/21/23 to make corrections to the visit date on that report. The visit date for that report should have been 08/25/23 not 08/21/23***

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced 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 08/17/2023, LPA Mora obtained copies of staff & resident rosters, and interviewed Assistant Administrator, Admission Director, and Resident 1 (R1). LPA also called to interview R1's home health agency, hospice agency, previous skilled nursing facility and placement agency. LPA obtained copies of R1’s face sheet, admission agreement, physician report and hospice care documentation. On 08/25/23, LPA interviewed Resident 1 (R1), Assistant Administrator, Resident Care and Planet Home Health Manager.

(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: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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-20230811103641

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: 09/14/2023

NARRATIVE

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The investigation revealed the following: regarding the allegation "facility placed resident on hospice without meeting criteria", it is alleged that R1 does not meet hospice criteria and facility placed R1 on hospice. Facility denied the allegation stated that they had nothing to do with R1’s hospice admission.
They also stated that when R1 arrived at the facility R1 already had a hospice referral. The placement agency representative that assisted the resident in finding this facility stated that they provided R1 the contact information of a hospice agency due to R1 being unhappy with the home health services, and that R1 made the decision to be admitted to hospice services and the facility had nothing to do with it. Review of hospice agency documentation shows that R1 signed the Hospice Admission Service Agreement on 08/03/2023. R1 is self-responsible and has no conservatorship. R1 was not able to provide much details that could assist with this investigation. R1 was confused about the whole situation and did not remembered signing the hospice documents or who talked to R1 about signing up to hospice.

Regarding the allegation "resident is not receiving care as needed", it is alleged that R1 was discharged from a skilled nursing with a doctor's order for R1 to receive wound care services from a home health agency and since facility placed R1 on hospice the resident is not receiving this service. Facility denied the allegation stated that R1 was receiving wound care services from home health and they have came to the facility on 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/12/2023, and 08/14/2023 per their sign-in sheet. However, once it was confirmed that R1 was on both hospice and home health, the home health agency discharged R1 and the hospice agency took over and provided the wound care services. Interview with Planet Home Health Manager on 08/17/23 confirmed this information. During 08/25/23 visit, Resident Care told LPA that R1 is back on home health and per their sign-in sheet they started coming as of 08/21/2023. LPA contacted the Planet Home Health Manager to confirm and the Planet Home Health Manager confirmed that R1 is back on home health and will be seen daily.

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: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

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