198603286-8-4-2023-28-AS-RORN-CXSNA9-20231121091708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 08/04/2023
Date Signed: 08/04/2023 03:05:10 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
07/28/2023 and conducted by Evaluator Ashley Calderon

COMPLAINT CONTROL NUMBER: 28-AS-20230728164224

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:	08/04/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Assistant Administrator- Alexander Solorio		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff did not ensure that residents were adequately fed.
Staff did not respond to residents call for assistance.

INVESTIGATION FINDINGS:

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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 today's visit.

On LPA collected staff and resident roster. Resident #1 (R1) Facsheet, Physican Report, and Appraisal Needs and Service. LPA collected service tracker for Residents #1 (R1), #2 (R2), #3 (R3) and #5 (R5) and collected current food menu, collected special diet list and alterative food slips. LPA interviewed Assistant Administrator Alexander Solorio, Staff #1-Staff #5 (S1-S5) and LPA interviewed residents #1-#7 (R1-R7).LPA along side with S1 toured the kitchen and dining room.

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: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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-20230728164224

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: 08/04/2023

NARRATIVE

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Based on allegation:Staff did not ensure that residents were adequately fed. Investigation revealed the following Assistant Administrator Alexander Solorio, Staff S1-S5 denied the above allegation and stated all residents are adequately fed, and stated R1 has food preference and facility accommodate R1's needs although R1 still refuses food at times. Interviews with R1-R7 revealed all residents are adequately fed and some have food preference but are still provided with adequate food. LPA Calderon observed a food menu, observed sufficient perishable and non-perishable food items for residents in care and observed kitchen having a list of residents who are on a special diet and R1 is not one of those residents.

Based on allegation:Staff did not respond to residents call for assistance. Interviews with staff Assistant Administrator Alexander Solorio, Staff S1, S3-S5 revealed residents who call for assistance are receiving assistance and are not waiting for a long period of time. Alexander and staff S1,S4 and S5 stated all residents are checked on and receive assistance even those who do not call,and residents have available and/or receive water and other liquids by facility staff. Alexander and S1, S4 and S5 stated the front desk receive calls from some residents inquiring assistance and caregivers are informed which resident is requesting assistance and staff will provide resident with assistance. Interviews with residents R1-R7 revealed residents get assisted and not all residents call the facility for assistance but are receiving assistance by caregivers and staff . R1, R2, R7 stated calling the facility and caregiver providing assistance. R1-R7 did not state having to wait got 6 hours and/or a long period of time.

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 allegations 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: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC9099 (FAS) - (06/04)

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