198603286-6-6-2023-28-AS-RORN-CY3P89-20231130100509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 06/06/2023
Date Signed: 06/06/2023 03:24:13 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
05/30/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230530122313

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: 70	DATE:	06/06/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Assistant Administratro -Alexander Solorio		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not notify resident's authorized representative that resident was missing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander Solario (Assistant Administrator) and explained the purpose of the visit.

During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters. Plan of Operation, Police Report #2023-34886, Communication text messages with Resident #1 (R1) authorized representative and facility staff, Special Incident Report, SOC 341, R1's Admission Agreement, Emergency ID, PrePlacement and Apprasial Needs and Service Plan. LPA Calderon interview Alexander Solorio, Staff #1-4 (S1,S2,S3,S4), interviewed telephonically R1 authorized representative, attempt to interview telephonically R1, and interviewed Residents #2-7(R2-R7).

Continution 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: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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-20230530122313

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: 06/06/2023

NARRATIVE

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Regarding the allegation: Staff did not notify resident's authorized representative that resident was missing. Interview with Alexander reported that R1's authorized representative was notified on 5/1/23 via telephone and Alexander provided police report number to LPA. Interviews with Staff #2-4 reported that police report was done by facility, R1 based on Physician Report is able to leave facility unattended and R1 authorized representative was notified. Interview with Resident R2, R3, R6 all stated they are able to leave the facility, and when a resident are not present at the facility they search for residents and call the police and file a report. LPA reviewed records. Facility submitted to Licensing a Special Incident Report (SIR) on 5/1/23 regarding incident involving R1. SIR states R1's authorized representative was contacted.
SOC 341 was submitted by facility to Licensing on 5/1/23 stating R1 absent without official leave incident occurring on 4/30/23 at approximately 5pm. SOC 341 states R1's authorized representative was notified on 5/1/23 as well as police on 5/1/23. LPA Calderon called Pasadena Police Department was reported that report was made by Pasadena Villa Assisted Living at 5:40pm. LPA reviewed reports, reports were made in a timely manner to appropriate representatives.

Based on LPA's interviews 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 Solario.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC9099 (FAS) - (06/04)

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