198603286-9-12-2023-28-AS-FFIS-CYJ4JQ-20231214180906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603286
Report Date: 09/12/2023
Date Signed: 09/12/2023 01:39:12 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
09/06/2023 and conducted by Evaluator Ashley Calderon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230906093033

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: 74	DATE:	09/12/2023
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Assistant Administrator- Alezander Solorio		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff did not comply with an infection control practice resulting in a H&S risk

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Calderon conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator Alexander Solorio and discussed the purpose of today's visit.

On today's visit, LPA collected resident and staff roster. Collected Mass testing results for staff and residents, staff in-service training roster conducted and materials regarding covid. LPA collected up coming flyer regarding in-service on covid policies and procedures. LPA collected Special Incident Reports regarding covid residents/ exposures and facility line list. LPA toured random residents rooms: 3,7,14,24,and 39. Along side Assistant Administrator LPA observed storage rooms that have sufficient ppe supplies and LPA observed ppe carts. LPA interview Residents #1-7 (R1-R7) and staff, Assistant Administrator and Staff #1-#5 (S1-S5).

(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: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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-20230906093033

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: 09/12/2023

NARRATIVE

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Regarding allegation: Staff did not comply with an infection control practice resulting in a H&S risk. Investigation revealed based on staff interviews with Assistant Administrator and Staff (S1-S5) all denied the above allegation, staff stated facility is following infection control policies and procedures, are cleaning and disinfecting rooms and common areas, wearing masks and encourage residents to follow covid policies. 6 out of 6 interviewed staff stated residents are not at a health and safety risks due to facility following covid practices. Interviews with residents R1-R7 all denied the above facility stating facility is not putting residents at a health and safety risk and are regularly cleaning and following covid policies and facility are following infection control practices. 4 out of 7 residents stated during interviews that staff encourage/ notify residents to follow covid practices like wearing masks and wash hands. LPA reviewed in-service training for staff scheduled with professional nurse/ Infection Preventionist on 9/15/23 regarding covid policies, training is conducted annually stated on Infection Control Plan LIC 9282. LPA reviewed in-service training roster/ material for dates 8/2/22 and 8/30/23. LPA reviewed infection control plan that has been updated and previously submitted to Licensing. LPA observed the facility is following infection control plan and Pasadena Public Health Guidelines based on interviews, observations and record review. LPA observed and toured random residents rooms: 3,7,14,24,and 39 all contained soap, hand sanitizers available for residents in hallways, and LPA observed covid signs in hallways, common areas and residents restrooms for covid precautions throughout the facility. LPA observed sufficient ppe supplies in storage closets and ppe bins containing disinfectant spray, gowns, gloves, masks, eye protection wear, booties, and hair nets. LPA toured facility, facility was observed clean.
LPA reviewed Special Incident Reports (SIRs) regarding covid, facility is taking action using covid precautions and are following covid procedures and policies, based on SIRs facility is reporting to the proper agencies like public health and licensing, are reminding residents on covid policies and procedures and are providing residents with medical help when needed. LPA did not observe a health and safety risk based on observation, interviews and record review. LPA was provided a line list, during time of visit there were 0 covid cases at the facility, therefore, based on interviews, record review and observations there was insufficient evidence to corroborate with this allegation.

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 allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided via email due to printer issues..

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley Calderon	TELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC9099 (FAS) - (06/04)

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