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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 11/30/2023
Date Signed: 11/30/2023 09:35:32 AM

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
05/25/2021 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210525125201
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: 78DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Maria Razo/Resident Care DirectorTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Personal Rights/Resident sustained injuries while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra met with Maria Razo/Resident Care Director. The purpose of today's visit is to deliver findings for the above allegation.

On 05/26/2021, Licensing Program Analyst (LPA) Nicole Spencer conducted a Health and Safety check visit in response to the above allegation. LPA met with assistant administrator Alex Solorio and explained the reason for the visit. The investigation consisted of the following: LPA Spencer requested a copy of Staff roster and Resident roster. LPA Spencer conducted a health and safety check which included a tour of the lobby, 5 resident rooms, dining room, outdoor patio, kitchen and food supply. LPA observed that there was at least a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. The facility was clean and in good repair and there were no observable signs of neglect, abuse or other immediate health and safety threats. During this visit, it was been determined that the above allegations will require further investigation.

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
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)
Page: 1 of 5
Control Number 28-AS-20210525125201
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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Allegation: Personal Rights/Resident Sustained injuries while in care.
The investigation for this allegation was conducted by Investigator Edward Hector. During this investigation, IB Investigator Edward Hector conducted interviews with the Wise & Healthy Aging Ombudsman, Staff #1 (S-1) through Staff #2 (S-2) and Resident #1 (R-1) through Resident #3 (R-3). Investigator Edward Hector obtained and reviewed R-2’s hospital medical records. Per Investigator Edward Hector, “staff admitted that there was a history prior to the incident that showed R-2 may have needed a higher level of care. Interviews of staff, residents and Investigator observations revealed that there was a lack of available staff and staff response when requested. There is sufficient evidence to support the allegation of lack of supervision resulted in R-2 sustaining injury”. LPA Irra obtained additional documentation which revealed that R-2 had (9) falls between 03/25/21 through 05/31/21. On 05/17/21, R-2 fell and sustained a pelvic fracture.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 1 is being cited.

Immediate Civil Penalties will be issued today, in the amount of $500.00 due to: Personal Rights/Resident Sustained injuries while in care.

Exit interview conducted. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421IM (Civil Penalty Assessment), and Appeal Rights were provided to Maria Razo/Resident Care Director
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
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)
Page: 2 of 5
Control Number 28-AS-20210525125201
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: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87411(a)
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Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This standard is not met at evidence by: "staff admitted that there was a history prior to the incident that showed R-2 may have needed a higher
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Facility Administrator to submit a statement indicating that the facility will update residents’ needs when there is a change in condition.

Immediate Civil Penalties will be issued today, in the amount of $500.00.
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 level of care. Interviews of staff, residents and Investigator observations revealed that there was a lack of available staff and staff response when requested. There is sufficient evidence to support the allegation of lack of supervision resulted in R-2 sustaining injury”.
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
05/25/2021 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210525125201

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: 78DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Maria Razo/Resident Care DirectorTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Personal Rights/Facility did not seek timely medical treatment for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra met with Maria Razo/Resident Care Director. The purpose of today's visit is to deliver findings for the above allegation.

On 05/26/2021, Licensing Program Analyst (LPA) Nicole Spencer conducted a Health and Safety check visit in response to the above allegation. LPA met with assistant administrator Alex Solorio and explained the reason for the visit. The investigation consisted of the following: LPA Spencer requested a copy of Staff roster and Resident roster. LPA Spencer conducted a health and safety check which included a tour of the lobby, 5 resident rooms, dining room, outdoor patio, kitchen and food supply. LPA observed that there was at least a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. The facility was clean and in good repair and there were no observable signs of neglect, abuse or other immediate health and safety threats. During this visit, it was been determined that the above allegations will require further investigation.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
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)
Page: 4 of 5
Control Number 28-AS-20210525125201
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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Allegation: Personal Rights/Facility did not seek timely medical treatment for resident.
The investigation for this allegation was conducted by Investigator Edward Hector. During this investigation, IB Investigator Edward Hector conducted interviews with the Wise & Healthy Aging Ombudsman, Staff #1 (S-1) through Staff #2 (S-2) and Resident #1 (R-1) through Resident #3 (R-3). Investigator Edward Hector obtained and reviewed S-2’s hospital medical records.

Per Investigator Edward Hector, “R-2 admitted to refusing services and not always notifying staff of unwitnessed falls. Staff advised that R-2 would regularly contact R-2’s social worker for assistance, instead of facility staff. Residents confirm that R-2 would routinely not ask for help from facility staff. There is insufficient evidence to support the allegation that staff had a failure to seek timely medical attention.

Although the allegation may have happened or are 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 conducted. A copy of this report and Appeal Rights were provided to Maria Razo/Resident Care Director

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
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)
Page: 5 of 5