198603295-4-22-2022-28-AS-WSHO-CECU56-20220512151615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 04/22/2022
Date Signed: 04/22/2022 02:28:29 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
04/18/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220418101232

FACILITY NAME:	PASA ALTA MANOR		FACILITY NUMBER:	198603295
ADMINISTRATOR:	CHERTOK, VLADIMIR		FACILITY TYPE:	735
ADDRESS:	1790 N FAIR OAKS AVENUE		TELEPHONE:	(626) 798-6986
CITY:	PASADENA	STATE: CA	ZIP CODE:	91103
CAPACITY:	90	CENSUS: 81	DATE:	04/22/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Staff / Estefany Lopez		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff interferes with client receiving mail.

Staff take personal items from client's room.

Staff is financially abusing client while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Estefany Lopez who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Staff interferes with client receiving mail, Staff take personal items from client's room and Staff is financially abusing client while in care."

During the course of the investigation, LPA interviewed the Facility Manager / Tricia Pedroza (via telephone), Staff members 1 - 3 (S1 - S3), Clients 2 - 4 (C2 - C4) and Client 1's (C1's) Case Manager (CM) at Department of Mental Health (DMH). C1 was not at the facility at the time of this visit. LPA made mulitple attempts to speak with C1 but was unsuccessful. LPA was unable to leave a voice message due to the mailbox being full. Also, copies of the following documents were obtained and reviewed in reference to C1;

• Client Face Sheet • Appraisal/Needs and Services Plan • Physician's Report • Functional Capability

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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-20220418101232

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: PASA ALTA MANOR	FACILITY NUMBER: 198603295
	VISIT DATE: 04/22/2022

NARRATIVE

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Assessment • Record of Client's/Resident's Safeguarded Cash Resources • Client/Resident Personal
Property and Valuables • Admission Agreement • Unusual Incident/Injury Reports / LIC 624s • House Rules

The investigation revealed the following;

Allegation: Staff interferes with client receiving mail. The details of this allegation states that C1 cannot connect with her physician because facility staff are withholding her mail. The Facility Manager has been withholding C1's mail or has given it to C1's CM at DMH.
Based on interviews conducted the statements obtained were inconsistent and did not corroborate with the allegation. Clients interviewed confirmed that there is no concern with staff interfering with clients mail. Staff interviewed denied withholding mail from clients. Interviews conducted with the Facility Manager and CM from DMH confirmed that often times important mail pertaining to C1 is given to the CM at DMH in order for the CM to discuss the details of the letter with C1 and to also ensure that C1 receives the mail and does not accuse facility staff of withholding mail. LPA discovered that, C1 has made the same allegation against the prior facility where she used to reside. Based on the information gathered, there is insufficient evidence to support the allegation to be true.

Allegation: Staff take personal items from client's room. The details of this allegation states that facility staff go into the rooms and take anything they want.
Based on interviews conducted the statements obtained were inconsistent and did not corroborate with the allegation. Clients and staff interviewed denied facility staff going into rooms and taking personal items from clients. LPA learned that Staff conduct random room checks to ensure clients do not have anything in their possession that could be a danger to themselves or others and a few times staff have found medication which does not belong to C1 in C1's room, at which time the medication was confiscated by staff and handed to the Facility Manager. Also, C1 has had multiple incidents involving bringing kittens onto facility property, which is a violation of facility house rules. On 11/30/21, C1 was issued an Eviction Warning for bringing kittens into her room multiple times. Based on the information gathered, there is insufficient evidence to support the allegation to be true.

Allegation: Staff is financially abusing client while in care. The details of this allegation states that facility staff have access to her social security income.
Based on interviews conducted and record reviews, LPA discovered that C1 had her SSI benefits reinstated

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220418101232

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: PASA ALTA MANOR	FACILITY NUMBER: 198603295
	VISIT DATE: 04/22/2022

NARRATIVE

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recently. Prior to receiving SSI benefits, C1's rent was funded through Brilliant Corners. According to the physician's report dated: 6/24/21, C1 is listed as independent and able to manage own cash resources. Interview conducted with the Facility Manager confirmed that C1 is listed as her own payee and is in charge of her SSI benefits. Facility staff only handle the disbursement of the P&I funds. LPA verified the records listed on the Record of Client's/Resident's Safeguard Cash Resources for C1 and did not observe discrepancies. Based on the information gathered, there is insufficient evidence to support the allegation to be true.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC9099 (FAS) - (06/04)

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