198603286-7-18-2023-28-AS-FFIS-CXP4RT-20231117182029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:27:13 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
07/13/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230713162451

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: 73	DATE:	07/18/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Assistant Administrator -Alexander Solorio		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide proper supervision to residents
Staff spoke inappropriately to resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ashley Calderon conducted a visit in response to the above allegations. On today's visit, LPA met with Assistant Administrator Alexander Solorio and discussed the purpose of todays visit.

On today's visit, LPA collected resident and staff roster. Collected Resident #1 (R1) Medical Notes, Discharge notes, Physician Report, Face sheet, Appraisal Needs and Service and Staff Communication Text for R1 Medical attention needs, Refusal Document for Medical needs dated 6/3/23, 6/14/23, and 7/2/23, and R1 Unusual Incident Reports , email to R1 team at A-Biz Health Systems and Resident #7 (R7) Unusual Incident Report for 6/19/23 and 6/26/23. LPA received Residents July Sign Out Sheet. and Staff Shift to Shift Reports. LPA visited residents room 8,11,21,27 and 31. LPA interview Resident #1-7 (R1-R7) and Staff Administartor and Staff #1-#3 (S1-3).
Continuation on 9099-C

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: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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 2

Control Number 28-AS-20230713162451

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: 07/18/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding Allegation: Staff did not provide proper supervision to residents. LPA Calderon interview 7 residents, 4 out of 7 residents stated they receive adequate supervision, get medical assistance when needed, staff assist when they request assistance and they notify front desk about their whereabouts when leaving to the community. LPA interviewed 4 staff all stated residents receive proper supervision, staff do their rounds, staff assist with any activity of daily living needs or medical needs, many residents are independent and staff communicate with each other on residents needs. LPA obtained and reviewed unusual incident reports that obtain information on how facility is providing appropriate care for residents. LPA obtained and reviewed Shift to Shift documentation obtaining documentation on residents care regarding residents appointments, medication changes, illness, injuries, behaviors, important issues to discuss or any medical needs that occur during staff shift to communicate with facility staff and provide resident proper supervision and care. LPA collected resident sign in and out sheet that provides facility with information on residents who leave to the community.

Regarding Allegation: Staff spoke inappropriately to resident. During LPA's visit LPA interviewed 7 residents. 5 out 7 residents denied the above allegation and stated staff do not speak to them inappropriately and have not heard staff talking with residents inappropriately and have not experienced the above allegation. LPA interviewed 4 staff all who denied above allegation and stated staff do not speak to residents inappropriately and speak to them professionally. LPA Calderon observed interactions with staff and residents during LPA's visit and did not observe staff talking inappropriately to residents in care.

Based on LPA's interviews, observations and record review investigation revealed: 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.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator Alexander Solorio.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2