198603295-4-28-2022-28-AS-WSHO-CF75PR-20220607200822

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:50:29 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
04/21/2022 and conducted by Evaluator Nune Margaryan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220421093504

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:	04/28/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Staff Estefany Lopez		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff member is verbally abusive towards clients in care.
Staff member inappropriately handled client's clothing.
Staff member threatens clients in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted a complaint inspection on the above allegations. LPA arrived unannounced and met with staff Estefany Lopez who assist with the visit. Shortly after Administrator Tricia Pedroza arrived. LPA explained the purpose of the inspection.

The investigation consisted of the following: LPA interviewed the Administrator , Staff members #1 - #3 (S1 - S3), Clients #3 - #6 (C3 - C6). Client #1 (C1) refused to talk with LPA. LPA was not able to interview Client #2 (C2). At the time of visit C2 was on home visit. LPA made multiply attempts to speak with C2 over the phone but was unsucssefull. LPA was unable to leave a voice message due to the mailbox was not set up yet.. LPA obtained copies of Staff & Clients rosters, reviewed C1's and C2's files and obtained copies of Face Sheet, Physician's Report, and Resident Appraisal, Functional Capability and other relevant documents.

The investigation revealed the following:
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Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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 3

Control Number 28-AS-20220421093504

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: 04/28/2022

NARRATIVE

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In regards the allegations “Staff member is verbally abusive towards clients in care” and “Staff member threatens clients in care”. It was alleged that staff verbally abusive towards clients, yells at the clients and clients feel threatened by staff.

Interview conducted with S1 denied these allegations. S1 denied threatening or yelling at C1, C2 or other clients. S1 stated that S1 is not verbally abusing the clients. All interviewed staff denied that S1 yelled or spoke to C1 in a threatening manner. Administrator indicated that there has not been any complaints/concerns that S1 or others verbally abusing the client, yelling or threatening the C1, C2 or other clients. Administrator stated that C1 needs 1 to 1 supervision all day and S1 and other staff from "Right Choice In -Home Care" agency assisting C1 24/7. Administrator stated that NLACRC (North Los Angeles County Regional Center ) founds the services from the agency. Interviewed staff members indicated that they treat all of the clients with respect and do not yell or threaten the clients. They treat all clients with respect and dignity. All staff also deny overhearing or being told that S1 yelled at C1 or C2. Interviews conducted with clients also denied these allegations and indicated that staff members do not yell at them or threaten them. Clients indicated that staff are nice and speak to clients appropriately. Based on the information obtained, the allegations are unsubstantiated.

In regards to the allegation “Staff member inappropriately handled client's clothing”. It was alleged that staff trashed client clothes.

Interview conducted with S1 denied this allegation. S1 stated never trashed C1's clothing. C1 changed his clothing 5 to 10 times a day and C1's clothes are all over the room. S1 helps to organize them. C1 needs assistance to separate dirty clothes and put them in the hamper to be washed. Housekeeper staff clean clients rooms daily and client's laundry is washed once a week. Interviewed staff stated that they are washing C1's clothes almost every day because C1 has a lot of clothing and changes them often. They stated that staff never trashed C1's or other clients clothing. Clients interviews revealed that staff are not trashing their clothes. Based on the interviews conducted there is insufficient evidence to support the allegation. Based on the information obtained, the allegation is unsubstantiated.

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NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220421093504

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: 04/28/2022

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	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 with Administrator Tricia Pedroza and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

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