198603295-12-1-2021-28-AS-LHIS-C9NSMN-20211213130014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 12/01/2021
Date Signed: 12/01/2021 03:45:00 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
11/24/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211124125828

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: 82	DATE:	12/01/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Tricia Pedroza		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility is in disrepair
Facility serves expired food

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegations. LPA met with Administrator, Tricia Pedroza who assisted with today's visit.

Regarding the allegation that the facility is in disrepair, specifically that the stairs are unsafe, the investigation consisted of tour of facility, and interviews with Administrator, and Residents #1 - #8. Administrator denied the allegation. Administrator stated that all of the residents are ambulatory and to her knowledge, none of the residents have fallen due to the stairs being unsafe. Administrator also stated that if a resident wants to move to a room on the ground level, they can accommodate them. Residents interviewed were unable to corroborate the allegation. 8 out of 8 residents interviewed stated that they do not have any problems with the stairs. Regarding the allegation that the facility serves expired food, the investigation consisted of review of facility food supply, facility menu, and receipts for food purchased on 11/30/21. Administrator denied the allegation, and stated that the facility purchases food weekly, and do not serve expired food.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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-20211124125828

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: 12/01/2021

NARRATIVE

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She said that residents are given alternate choices if they do not like what is being served. Residents interviewed were unable to corroborate the allegation. 8 out of 8 residents stated that they are satisfied witht the food that is served. They said that the quality and quantity of food provided is good.

Based on LPA's observations and interviews, investigation revealed: 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.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Administrator, Tricia Pedroza.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC9099 (FAS) - (06/04)

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