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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 08/03/2022
Date Signed: 08/03/2022 12:16:21 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
09/24/2020 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200924143316
FACILITY NAME:PASA ALTA MANORFACILITY NUMBER:
198603295
ADMINISTRATOR:CHERTOK, VLADIMIRFACILITY TYPE:
735
ADDRESS:1790 N FAIR OAKS AVENUETELEPHONE:
(626) 798-6986
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:90CENSUS: 79DATE:
08/03/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Estefany Lopez, Assistant AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Client was sexually abused while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Assistant Administrator, Estefany Lopez who assisted with today's visit. Regarding the allegation that Client #1 was sexually abused while in care. The investigation consisted of review of Client #1's file, including review of special Incident reports dated 9/10/20, and 9/17/20, interview with Administrator, and interview with Client #2, who was Client #1's former roommate. LPA was unable to interview Client #1. Client #1 was hospitalized during initial visit, and did not return to the facility. The investigation revealed that Client #1 lived at the facilty from 9/3/20- 9/16/20. Special incident reports indicate that during the period of time that Client #1 was residing at the facility, Client #1 was refusing medications, had erratic behavior, and did not want to stay at the facility. Special incident report dated 9/16/20 states : Client #1 was verbally abusive towards staff, and behaving agressively towards other residents, client #1 was standing in the street yelling "Rape" and "Fire" at people passing by. On 9/16/20, Client #1 was transferred to hospital on a voluntary psychiatric hold. LPA made attempts to contact Client #1's mental health services provider. Per Administrator, facility conducted an internal investigation and found no indication that Client #1 had been sexually abused while in care.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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-20200924143316
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: 08/03/2022
NARRATIVE
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Based on LPA's observations and interviews, 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 to Assistant Administrator, Estefany Lopez.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2