198603286-11-2-2023-28-AS-RORN-CXKUVW-20231114145550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:43:30 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
03/02/2021 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210302100806

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: 74	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	01:57 PM
MET WITH:	Alexander Solorio - Administrator		TIME COMPLETED:	03:56 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's needs are not being met
Administrator is unavailable
Staff did not clean resident's room
Staff did not safeguard resident's personal belongings
Facility did not maintain a comfortable temperature for resident
Staff not following resident's dietary plan
Staff not serving meals in a timely manner

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegations listed above. LPA met with Alexander Solorio, Administrator for the facility, and explained the reason for the visit.

The investigation consisted of the following: during the initial visit conducted on 06/11/2021, LPA Joe Katrdzhyan obtained documents from Resident #1's (R1) file, along with a copy of the staff roster and resident roster, and on the subsequent visit LPA Zaragoza interviewed Residents# 2 – 11 (R2 - R11), Staff # 1 – 5 (S1 - S5), and toured rooms #3, 7, 18, 21, and 27. LPA Zaragoza also obtained copies of the following documentation during the subsequent visit: Staff Roster, Client Rosters, List of Residents with a Specialized Diet, along with the Admissions Agreement, Physician's Report, Appraisal/Needs and Services Plan, Functional capability assessment, Care Plan, and Inventory list for R1. During today’s visit, LPA Zaragoza interviewed Staff #6 (S6). LPA attempted to interview R12, however R12 is no longer a resident at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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 8

Control Number 28-AS-20210302100806

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: 11/02/2023

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

The investigation revealed the following: In regards to the allegation “Resident’s needs are not being met”, it was alleged that staff did not meet the needs of R1 by not assisting R1 with their showering needs in weeks, and also did not assist R1 with brushing their teeth or responding to the pendant call light system when the residents request assistance. During interviews with the residents, nine (9) out of eleven (11) interviewed did not corroborate the allegation that their needs were not being met. R3 explained that the facility staff always assists R3 with their diaper changing needs and has no issues with their needs being met, and R10 explained that the facility staff does respond to the resident’s call light system in a timely manner. During interviews with the staff, none of them corroborated the allegation that they do not meet the resident’s needs. S1 explained that caregivers of the facility spent a lot of time in R1’s room due to her needs, and that the resident received 2 showers per week, or on an as-needed basis.

In regards to the allegation that the “Administrator is unavailable”, it is alleged that the administrator of the facility Alexander Solorio is unreachable, never responds to any of the residents’ requests and blocks their calls. During interviews with the residents, eight (8) out of eleven (11) residents interviewed did not corroborate the allegation that Alex is not available to speak with and assist the residents of the facility. R2 explained that Alex is very nice, helpful, and available for the residents, and R10 explained that Alex assists R10 with scheduling transportation for doctors appointments and that the communication between them is good. During interviews with the staff, none of them corroborated the allegation that the administrator Alex is not available for the residents. S3 explained that Alex often works on the floor of the facility to assist with caregiving duties when the other staff ask for assistance. During an interview with Alex over the phone, he stated that he is very hands-on in his work with the facility, and that he also makes rounds personally to ensure the needs of all residents are being met. He states that he has an open door policy and that any resident that has questions, requests, or concerns to come talk to him, and if he is ever busy he will inform the resident of when he will become available.

In regards to the allegation that “Staff did not clean resident’s room”, it was alleged that the resident rooms were not cleaned by the staff members when they should have been. During interviews with the residents, nine (9) out of eleven (11) interviewed did not corroborate the allegation that staff do not clean their rooms. R2 explained that the housekeepers clean R2’s room every other day and also make sure to take the trash out of residents rooms if there ever is any trash visible, and R6 also stated that he gets his room cleaned by the staff and that it is done in an adequate manner.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 28-AS-20210302100806

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: 11/02/2023

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

During interviews with the staff, none of them corroborated the allegation that fellow staff members do not clean the rooms of the residents. S1 explained that each of the resident rooms get a deep cleaning at least once per week, and every other day rooms are checked to see if any trash needs to be thrown away, and S4 stated that at the time this complaint was filed it was more difficult to the zoning restrictions that the facility implemented from the Department of Public Health, however they did make sure to clean the rooms at least once per week when this complaint was filed.

In regards to the allegation that “Staff did not safeguard resident’s personal belongings”, it was alleged that multiple possessions of R1’s had either gone stolen or missing during R1’s time living in the facility, including clothing, a Christmas Package, a chess set, and a polo winter vest that the facility replaced with an imitation vest. During interviews with the residents, nine (9) out of eleven (11) did not corroborate that their personal items have been stolen. Most of the residents indicated that they have never had one of their personal items go missing in the entire time they have lived in the facility, and all residents who have lived in the facility at the time the complaint was filed claimed none of their belongings have gone missing or gotten stolen. During interviews with the staff, none of them corroborated the allegation that they have failed to safeguard the personal belongings of the residents. S1 stated that she never recalled R1 reporting that her personal belongings had gone missing, and that in the event that this does occur they ask residents to report it as soon as possible so they can work toward finding it by first search the resident’s rooms and then around the facility, and if the item is of sufficiently high value they will also file a police report. S4 stated that R1 had nothing listed on their inventory log, and that they did once complain about not receiving a package, however it did eventually arrive, it was just two (2) days late. During record review of R1’s personal inventory list, they waived their right to have any of their personal belongings safeguarded by the facility staff.

In regards to the allegation that “Facility did not maintain a comfortable temperature for resident”, it was reported that the temperature in their resident rooms were between 80-82 degrees, and that staff were deliberately turning off their air conditioning or refusing to turn it on. During interviews with the residents, seven (7) out of the eleven residents interviewed did not corroborate that the temperature is too hot or cold. R2, R4, and R7 all stated that at times the temperature in their rooms can feel a bit cold, however when they ask the facility staff to change the temperature they do help them with adjusting it. During interviews with the staff, none of them corroborated the allegation that they do not keep a comfortable temperature for the residents in the facility. During the physical plant tour of the facility, LPA measured the temperature in the air to be at 74 degrees Fahrenheit in all rooms of the facility and that it was of a comfortable temperature.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 28-AS-20210302100806

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: 11/02/2023

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

In regards to the allegation that “Staff not following resident’s dietary plan”, it is alleged that staff was feeding R1 carbohydrate-heavy meals, when R1 was a diabetic and those types of meals were not appropriate for them. During interviews with the residents, ten (10) out of eleven (11) did not corroborate the allegation that residents who have a specialized diet do not get food suited to their diet. LPA interviewed R2, R3, R8, and R9 because they were all indicated to require a diabetic diet, and none of them corroborated that the facility does not follow a resident’s specialized dietary plan if they require one. During interviews with the staff, none of them corroborated the allegation that the facility does not follow the dietary plans of the residents. S3 who works with the kitchen staff stated that within the kitchen of the facility there is a list of the resident’s dietary restrictions and their care plan which details what residents can and cannot eat so that staff know to avoid certain foods with residents. Additionally S4 explained that the facility staff did provide R1 food appropriate for R1’s diabetic diet which was submitted to them through their Care Plan by their physician, however R1 was not happy with the food that the facility offered and often went against their own Care Plan by ordering food from outside dining establishments. During the physical plant tour of the facility LPA observed in the kitchen that the facility does have a list of dietary restriction and Care Plans for all residents that require a specialized diet posted in an area where all kitchen staff can see it.

In regards to the allegation that “staff are not serving meals in a timely manner”, it was alleged that around the time this complaint was filed in March of 2021 that food was being delivered to resident rooms late, that the food was served cold, and that staff did not respond to requests to reheat the food. During interviews with the residents, ten (10) out of eleven (11) interviewed could not corroborate the allegation that their food is not served warm. R5 and R6 both lived in the facility around the time that this complaint was filed in March of 2021 and they both explained that the facility did serve meals in a timely manner and never experienced an issue with being served cold meals around this time or in the present day. During interviews with the staff, none of them corroborated the allegation that meals are not served to residents in a timely manner. S1 explained that R1 was served meals on time which was delivered to her room, and that the facility’s kitchen staff made sure to wrap food in saran wrap to ensure that food got delivered warm to residents, and S4 said that around this time it was more difficult for residents to be delivered their food due to the zoning restrictions the facility had to implement due to COVID-19 which forced them to deliver food to residents one zone at a time, however each resident did get their food delivered in a timely manner at the time this complaint was reported and in the current day as well as kitchen staff make sure to deliver food to residents who eat in their rooms first to ensure that it stays warm.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 28-AS-20210302100806

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: 11/02/2023

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

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 above allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 8

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
03/02/2021 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210302100806

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: 74	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	01:57 PM
MET WITH:	Alexander Solorio - Administrator		TIME COMPLETED:	03:56 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is without hot water

INVESTIGATION FINDINGS:

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

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 28-AS-20210302100806

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: 11/02/2023

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

In regards to the allegation that “Facility is without hot water”, it is alleged that there is not hot water in the showers or faucets of the resident bathrooms. During interview with the residents, three (3) out of eleven (11) interviewed corroborated the allegation that the water is too cold. R6 explained that the water has not been sufficiently hot in his time living at the facility, which has been since before the complaint was filed. A separate resident who was not fully interviewed, Resident #13, told LPA and the Resident Care Director Maria Razo in a hallway during the physical tour of the facility that the water in R13’s room was too cold for them to take a shower that morning. During an interview with the staff members, none corroborated the allegation, however they did explain that in certain rooms it can take time for the showers to warm up. S1 explained that it can take 5 – 10 minutes for hot water to turn on in the morning in certain rooms while the hot water temperature is within range for other rooms, and that maintenance is working on the issue and additionally that maintenance states that the issue is being caused by old pipes. S4 likewise stated that hot water is delivered to all rooms in the facility however it can take 5-10 minutes for the hot water temperature in some rooms to reach the required range, and that this is due to the building being old. LPA measured the hot water temperature in rooms 3, 7, and 18 and they all measured 102.3 Degrees F, 88.7 Degrees F, and 84.5 Degrees F respectively.

Based on LPAs interviews conducted with the residents and staff, the preponderance of evidence standard has been met for the above allegation, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099D.

Exit interview held and a copy of the report and appeal rights was provided to the administrator Alexander Solorio.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 28-AS-20210302100806

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: 11/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/17/2023 Section Cited CCR 87303(e)(2)	1 2 3 4 5 6 7	87303 (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water (...) to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator shall ensure that the hot water temperature will remain within the required range at all times. Administrator will maintain a log of water temperature for the above resident rooms by the POC due date.
	8 9 10 11 12 13 14	Based on interviews and observation, LPA determined that the hot water temperature in the facility fell below the 105 degree threshold in Rooms 3, 7, and 18, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 8