198603286-10-3-2023-28-AS-RORN-CWWVTG-20231024164306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:46:50 AM

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
08/10/2023 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230810135252

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: 72	DATE:	10/03/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alex Solorio- Assistant Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident in care was assaulted by unknown individual in the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analys (LPA) V. Maldonado made a subsequent unannounced visit at the facility for the purpose of continuing the investigtion regarding the above-mentioned allegation. LPA Maldonado met with Assistant Administrator Alex Solorio and explained the purpose for the visit.

On 8/17/23, LPA Maldonado made an initial complaint visit and obtained a copy of the resident and staff roster, and the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Needs and Services Plan, incident reports for July-August 2023, and police reports- if any. LPA also requested to review surveillence video footage for the night of 08/08/23, but was unable to due to time contraints. LPA also interviewed Staff# 1 (S1).

During today's visit, LPA conducted interviews with Residents# 2-7 (R1-R7) and Staff# 1-3 (S1-S3). LPA was unable to interview R1 due to R1 being out of the community during the visit. No additional contact information for R1 was avilable for LPA to attempt a telephone interview. (Report continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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-20230810135252

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: 10/03/2023

NARRATIVE

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The investigation revealed the following:

Regarding allegation: Resident in care was assaulted by unknown individual in the facility.
It is alleged that on Sunday, August 8, 2023 at about 10PM, R1 was using the phone in the staff area and was confronted by a staff named Salvador, who yelled at and hit R1 with two closed fists to the chest, for being in a restricted area. After review of R1’s Physician’s Report, dated: 1/24/23, it was discovered that R1 has an altered mental status and has a history of substance abuse. Per R1's Needs and Serviced Plan, dated: 2/17/23, R1 has frequent outbursts towards other residents and staff due to exhibits of paranoia. It is also noted that R1 is normally alert and oriented, but appears to be disoriented and confused at times due to substance abuse. Per interviews conducted, (3) of (3) staff stated that R1 called the police to report the alleged incident. The police came and investigated the incident with S1, however, it was discovered that there are no staff working at the facility by that name. The police and staff also confirmed through review of surveillance footage that R1 was never in the area during the time R1 stated to have been, when the incident occurred. Per the staff roster, LPA confirmed there is no staff by the name, Salvador. During today's visit, LPA was unable to review surveillance footage for the date of 8/08/23, due to the system keeping footage for the last 30 days only, and no longer available. Per interview with R4, it was stated that R1 told R4 about the incident of staff hitting R1. However, R4 states R4 did not observe any marks on R1 that would indicate R1 was physically assaulted. R4 stated to "personally believe" R1 "hallucinates at times". R1 did not tell R4 who the staff was, where the incident occurred, and when it occurred, but simply stated R1 was hit by a male staff. (4) of (6) residents interviewed could not corroborate the allegation. This allegation is Unsubstantiated.

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.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited.

An exit interview was conducted with Assistant Administrator, Alex Solorio, and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC9099 (FAS) - (06/04)

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