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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 03/10/2023
Date Signed: 03/10/2023 12:33:16 PM

Substantiated


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
09/25/2020 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200925154403
FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 66DATE:
03/10/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Asst. Administrator, Alexander SolorioTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff not assisting resident with ADLs.
Staff did not observe changes in resident's health.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent unannounced visit at the facility for the purpose of investigating and deliver findings to the above-mentioned allegations. LPA Pena met with Assistant Administrator Alexander Solorio and explained the purpose for the visit.

During the initial visit on 9/29/2020, Licensing Program Analyst (LPA) Renee Arterberry conducted an unannounced 24 Hour Health and Wellness Check telephonically and virtually (via FaceTime) with Alexander Solorio facility administrator and facility nurse Marisol Cruz, employees of the facility. LPA Arterberry interviewed S1-S2, reviewed the facility file for R1, obtained copies of the following documents: Identification Page/Face Sheet, Pre-Appraisal Assessment, Medication Administration Record (MAR), Admission Agreement, Medical Assessment, Unusual Incident Reports (SIR) and hospice documents. LPA Arterberry also toured the physical plant: kitchen, dining room, and medication room.

During the subsequent visit on 2/17/2023, Licensing Program Analyst (LPA) Bennette Pena conducted a tour of the physical plant and obtained copies of the following documents: current resident/staff roster and R1's files such as: Face sheet, Physician's Report, Admission's Agreement, Resident Appraisal, Hospice Health Information, Incident Reports and Medication Administration Records (MARs) for Aug 2020-Oct 2020. LPA also interviewed Resident #2 (R2) - Resident #6 (R6), Staff #1 (S1), Staff #3 (S3), Staff #4 (S4) and telephonically interviewed Staff #2 (S2).

During today’s visit, Licensing Program Analyst (LPA) Bennette Pena obtained additional documents for R1 such as: National Rehab Center Discharge Instructions (dated 8/11/2020), Plan of Care (POC) Summaries (dated 9/09/2020, 9/24/2020), Physician’s medication order (dated 10/02/2020) and Huntington Hospital Discharge Instructions (dated 10/02/2020). *****CONTINUED ON LIC9099-C*****
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
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 3
Control Number 28-AS-20200925154403
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: 03/10/2023
NARRATIVE
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The investigation revealed the following:

Regarding allegation: "Staff not assisting resident with ADLs." It is alleged that R1 was weak and in severe discomfort, has been in pain for 8 days and constipated for 3 days with a pain level of 10 out of 10 and nausea level 8 out of 10. Based on documents reviewed, on 9/23/2020 R1 was admitted at Huntington Hospital and assessed by EMS. EMS observed R1’s “urine in the Foley to be dark in color and cloudy”. LPA reviewed R1’s Medication Administration Record (MAR) for Sep 2020 and it revealed that R1’s medication Zofran was not administered, and pain medication Morphine was last given on 9/20/2020 & 9/21/2020, two (2) days prior to R1’s hospitalization. Hospice communication log revealed that on 9/21/2020, Hospice RN reported the following: R1’s Foley catheter was not changed the night before, Foley was leaking around and Foley drainage slightly cloudy. (5) out of (6) residents interviewed indicated that they are independent in many ways, and they only need assistance with medication. Interviews conducted with staff members indicated that the Med-Tech and Caregivers were trained to clean and drain the Foley catheter bag. Staff also revealed that the facility’s daily notes and log were communicated verbally.

Regarding allegation: “Staff did not observe changes in resident's health.”


It is alleged that R1 started experiencing pain two (2) days after a Foley catheter was placed. But facility staff do not check on R1 enough and that he has been in pain for 8 days and constipated for 3 days with a pain level of 10 out of 10 and nausea level 8 out of 10. Based on documents reviewed, on 8/11/2020, R1 was admitted for care at the facility per admission agreement. Then R1 was admitted on 9/23/2020 at Huntington Hospital and assessed in by EMS, “urine in the Foley to be dark in color and cloudy”, “weak and in severe discomfort, with a pain level of 10 out of 10 and nausea level 8 out of 10.” EMS observed “rigidity, pain, distension, and tenderness in all four quadrants” of R1. (5) out of (6) residents interviewed indicated that they are able to do daily living activities on their own and they only need assistance with medication. Interviews with the staff revealed that there were enough staff per shift to check on residents and the facility’s daily notes and log were only communicated verbally.

Based on LPA’s interviews, and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to the facility failed to observe changes in resident’s health which resulted in resident experiencing severe pain and discomfort while in care. Refer to LIC 421IM***

At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date.

An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator Alexander Solorio along with the Appeals Rights.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200925154403
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: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2023
Section Cited
CCR
87459(a)(5)(B)
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87459 Functional Capabilities ...(a) The facility shall assess ....personal assistance and care ... to perform specified activities of daily living...(5) Continence, including: (B) Whether assistive devices...catheter are used.
This requirement is not met as evidenced by:
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The Administrator will implement a Restricted Health Condition Care Plan in place and have a licensed professional provide training to all staff on catheter care and assistance. Proof of staff training including topics covered,
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Based on observation, interviews, records review, the Administrator did not comply with the section cited above in that R1's need for personal assistance and care was not met as R1 was observed in by EMS, “urine in the foley to be dark in color and cloudy” which posed a potential health and safety risk to residents in care.
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duration and the name and signatures of staff and the licensed professional, shall be submitted to LPA Bennette Pena by POC due date.
Type A
03/13/2023
Section Cited
CCR
87466
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87466
Observation of the Resident..The licensee shall ensure...observed for changes in physical, mental, ...functioning ....appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented...resident's responsible person, if any. This requirement is not met as evidenced by:
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Administrator to provide an in-service training on Observation of the Resident regulations. Administrator will submit a copy of the training sign-in log with staff names and signatures, date, duration of training, name of trainer and curriculum used to LPA Bennette Pena by POC due date.
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Based on observation, interviews, records review, the Administrator did not comply with the section cited above in that the condition that the resident was observed in by EMS, “urine in the foley to be dark in color and cloudy”, “EMS observed rigidity, pain, distension, and tenderness in all four quadrants” and “R1 was weak and in severe discomfort with a pain level 10 out of 10 and nausea level 8 out of 10" which posed a potential health and safety risk to residents in care.
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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 SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023
LIC9099 (FAS) - (06/04)
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