198603286-11-30-2023-28-AS-RORN-CYA276-20231206160814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 11/30/2023
Date Signed: 11/30/2023 04:44:44 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
11/27/2023 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231127165020

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: 78	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Maria "Luisa" Razo		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility illegally evicted a resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit in response to the above allegation. LPA met with Maria “Luisa” Razo (Resident Care Director) and discussed the purpose of today's visit.

The investigation consisted of the following:

During today's visit, LPA interviewed Staff members 1 - 5 (S1 - S3) and Resident 1, LPA obtained the following copies from R1’s File: Physician’s Report, Needs and Service Plan, Behavior Contract, Incident Reports, copy of the Written 30-day Eviction Notice, and Facility House Rules.

(Continued on the 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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-20231127165020

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: 11/30/2023

NARRATIVE

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The investigation revealed the following:

Allegation: Facility illegally evicted a resident in care.

It is alleged that R1 was evicted from facility and there was no notice or reason provided on eviction.
LPA reviewed R1’s file and found copies of the 30-day eviction notice, with reasoning for eviction, dated 11/20/23. LPA reviewed multiple incident reports for R1 that document dates where resident had left facility and suffered a fall while out in the community, upon return to the facility, resident will appear to be confused, disoriented, lethargic and refusing care. Interviews with staff 5 out of 5 staff stated that R1 will often leave the community and get lost, be returned to the facility by neighbors, pedestrians, and law enforcement on many occasions. 5 out of 5 staff also stated that R1 is an over all friendly and calm resident when sober, however, when intoxicated is when R1 becomes aggressive and refuses care. Staff stated that R1 has returned to facility after being out in the community aggressive, confused, disoriented and what appears to be intoxicated. R1 has been on a Behavior Contract since 7/2/2023 due to noncompliance in following House Rules and aggressive behavior towards staff and residents. LPA interviewed R1, and resident stated that they were informed about the eviction but was not sure why they were being evicted. R1 also stated that they did sign the eviction letter on 11/20/23 but does not have a copy LPA provided copies of 30-day eviction notice and reasoning's behind eviction to R1 prior to end of visit. R1 further stated that there have been times where they would get lost in the community but this hasn’t happened in a long time, when asked about aggressive behavior towards other residents R1 stated that there have been a few altercations but that is in the past and all parties have reconciled since then. R1 did not appear to be confused or disoriented during visit.

Based on statements and interviews conducted with Staff and R1, and review of R1's files, there was not enough supportive evidence to concur with the reported allegation. 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. Exit interview held, and a copy of this report was provided to Luisa Razo.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

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