198603295-5-4-2022-28-AS-LHIS-CEHLCC-20220517083807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 05/04/2022
Date Signed: 05/04/2022 08:06:14 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
04/25/2022 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220425132304

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:	05/04/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Estefany Lopez		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff member is physically abusive towards residents in care.
Staff member enters resident's room uninvited.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced 10 day complaint visit to this facility and met with Staff Estefany Lopez to discuss the purpose for todays visit. Administrator Tricia Pedroza allowed staff to sign on her behalf.

The investigation consisted of: Interviews with staff, clients, and other parties. LPA Wesley requested a copy of the staff roster, resident roster, incident reports, Pasadena Police Officer Arambulo's police report dated 04/21/22, ID page, Physician's reports, and specific documents for client #1, and client #2

Regarding allegation: Staff member is physically abusive towards residents in care. During the investigation it was revealed that client #1 receives 1:1 services funded by the North Los Angeles County Regional Center(NLACRC) through the Right Choice agency due to their inappropriate behaviors and continued

Continued on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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 2

Control Number 28-AS-20220425132304

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: 05/04/2022

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

violations of the facility house rules. During the interview with third party staff #1 who provides 1:1 care and supervision for client #1 said they are not physically or verbally abusive to client #1 and did not grab them by the neck/shirt and push or pull them around and did not slam any doors in client #2's face(room mate who does not require 1:1 assistance). Staff#1 indicated that they have to ensure client #1 receives basic life skills which includes attending a day program, laundry, fold their clothing and keeping their room and surroundings clean and organized. Staff #1 said that they are required to keep checking on client #1 at a minimum of every 15 minutes to ensure client #1 does not harm them self or others. During the interview with client #2 they indicated they they are scared of staff #1 and identified the Right Choice staff(staff#1) as an African American male who is 6'3 and wears a black hoodie sweatshirt, black pants and a black mask. Client #2 could not describe any specific incidents to support that staff #1 grabbed client #1 by the back of the shirt by the neck and pushed and pulled them around. Client #2 said that staff #1 verbally forces client #1 to do things like cleaning, and said staff #1 was being a nuisance because they make client #1 complete their elements of daily living. Facility staff #2 and staff #3 were interviewed and said they are not physically abusive to residents in care and has never witnessed staff #1 abuse client #1. On 04/21/22 Pasadena Police Officer Arambulo reviewed the facility surveillance footage of the encounter and it revealed that staff #1 did not touch client #1 or client #2. During the interview with client #1 they said that staff #1 is abusive because they make them stand out and look like a bum which is socially embarrassing while out in the community with no money. The investigation revealed that there is no evidence to support the allegation.

Regarding allegation: Staff member enters resident's room uninvited. During the investigation it was revealed that client #1 receives 1:1 Services funded by the NLACRC through the Right Choice agency due to their inappropriate behaviors and continued violations of the facility house rules. Staff #1 said that they are required constantly checking on client #1 at a minimum of every 15 minutes to ensure client #1 does not harm them self or others. Client #2 said they do not feel comfortable with staff #1 entering into their room at any time and are scared that they have a room key. Client #2 has recently relocated to a different room and said they wish they were back in the room with client #1 because they are not comfortable with their new room mate.

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.

There are no deficiencies cited. A copy of this report was given during the exit interview.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Nicol Wesley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2