198603286-11-13-2023-28-AS-TVAO-CXRV4Z-20231120150709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 11/13/2023
Date Signed: 11/13/2023 01:27:36 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
08/14/2023 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230814105348

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:	11/13/2023
		UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Alexander Solorio - Assistant Administrator		TIME COMPLETED:	01:43 PM

ALLEGATION(S):

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Staff did not ensure resident was clothed
Staff did not ensure resident had eaten
Staff did not check on resident during the night

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit at the facility regarding the above allegations. LPA met with Alexander Solorio and explained the reason for the visit.

The investigation consisted of the following: On 8/22/23 LPA Trueman conducted an initial investigation visit and collected documents. On 11/13/23 LPA Flores conducted interviews with assistant administrator, 3 staff, and 6 residents. LPA collected the following documents: physician’s report, admission agreement, identification and emergency information, medication sheet for July – September 2023, needs and care plan, incident report dated 8/12/23, other documents for resident #1 (R1).

The investigation revealed the following: Regarding allegation: Staff did not ensure resident was clothed. It is alleged R1 was completely nude sitting on R1’s wheelchair outside the facility around 9:50am.
(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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-20230814105348

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: 11/13/2023

NARRATIVE

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Interviews conducted with residents revealed, residents stated that upon residents needing assistance in a situation like R1’s caregivers attempted to assist residents by redirect them even when the residents refuse. Interviews with staff revealed providing assistance with dressing to the residents is part of their duties. There are times when residents become impatience and they may go out without clothes. Residents become distraught and refuse caregivers’ assistance. Caregivers at that point seek for management’s assistance to help the residents. Document reviewed revealed; Incident Report dated 8/12/23 notes the morning of 8/12/23 at 9:00am management observed R1 “was naked in the front patio. Caregiver and manager attempted to assist R1 to return inside and get changed but refused. Management proceeded to set up transportation for a 5150 and contacted Pasadena Police Department”. Additional incident report notes, on 8/12/23 staff attempted at least 5 times to provide care to R1, who refused each time. Although R1 may have been nude, staff attempted to assist and redirect R1 to get dress. However, R1 refused the assistance. Due to R1’s behavior, management team reached out to Pasadena Police Department to assist with a 5150 for R1 to provide proper care.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff did not ensure resident had eaten. It is alleged R1 was upset because R1 wanted food when found outside around 9:50am. Interviews conducted revealed 5 out of 6 residents stated facility provides meals, reminders, or assistance with feeding the residents. 1 out of 6 residents stated to not be receiving meals at the facility as resident is out most of the day. Interviews with staff revealed residents receive meals three times a day and staff provides assistance with feeding to those residents that cannot feed themselves. Assistant administrator stated R1 can feed self as long as R1’s prosthetics are on. Document review revealed R1’s physician’s report notes R1 needs assistance with feeding. However, needs and service plan notes R1 is able to feed self and staff will assist as needed. Incident report dated 8/12/23 notes staff prompted assistance to feed R1 on 8/12/23 during breakfast but R1 refused the assistance. Although R1 may have wanted food and did not receive breakfast the morning of 8/12/23, staff attempted to provide breakfast and R1 refused the assistance.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.(CONT.LIC9099C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230814105348

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: 11/13/2023

NARRATIVE

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Regarding allegation: Staff did not check on resident during the night. It is alleged R1 was naked in the morning because R1 had not been checked up on during the night. Interviews conducted with residents revealed, 5 out of 6 residents stated there is staff overnight, who provide assistance or check on the residents as needed and 1 out of 6 residents stated assistance is not provided at night. Interviews with staff revealed that part of the duties of the night shift is to check on the residents during the night and provide care as needed. Documents reviewed revealed, Personnel Report notes there is at least 1 staff during the night shift on duty. Appraisal/needs and services plan dated 3/14/23, notes R1 is to receive assistance with activities of daily living (ADL)’s as needed and provide “extra assistance” with physical health services. However, it also notes R1 is non- compliant with care provided. Although facility staff has been providing care, R1 has not been complaint with staff. LPA was provided a copy of communication between assistant administrator and agencies involved in R1’s care in which R1’s non-compliance is discussed and a plan of action is discussed to better assist R1.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Alexander Solario and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC9099 (FAS) - (06/04)

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