198603295-8-30-2022-28-AS-RORN-CHZPMQ-20220906112643

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 08/30/2022
Date Signed: 08/30/2022 11:06:52 AM

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
04/22/2020 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200422141128

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: 78	DATE:	08/30/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Tricia Pedroza, Co-Owner/Acting Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility is unclean.
Inadequate food service.
Untrained staff.
Facility not following COVID-19 guidelines.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Co-Owner/Acting Administrator (A1) Tricia Pedroza. LPA/RA spoke to A1 prior to entering the facility to conduct a risk assessment. A1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms; and, they have been cleared by the Pasadena Health Department, effective 08/29/22.

The purpose of this visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day virtual visit was conducted by LPA Patricia Rivas on 04/28/20 (via telephone) with Co-Owner/Acting Administrator (A1) Tricia Pedroza due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros interviewed (between 8:30 a.m. - 9:30 a.m.) four (4) staff members and three (3) residents in care. LPA/RA reviewed and/or obtained pertinent documents (between 9:45 a.m. - 10:00 a.m.) Staff & Residents' Rosters; documentation

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

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-20200422141128

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: 08/30/2022

NARRATIVE

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showing face masks were provided to clients, training documents for the medication technicians; facilitymonthly menu. LPA/RA Ceniceros toured the facility's dining room, common bathrooms, and the commercial-size kitchen.)

Regarding Allegation #1: this investigation revealed that the housekeepers and/or kitchen staff clean the dining room area floors - following meals and housekeeping maintains the floors in the clients' rooms. (LPA/RA Ceniceros toured the facility and observed the floors to be clean.) Facility staff and clients interviewed corroborated that housekeeping does a very good job of maintaining the facility's cleanliness including the clients rooms. LPA/RA Ceniceros toured the common bathrooms and observed them to be sanitary including the floors and walls were clean.

Based on the observation and interviews conducted, 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 of PHYSICAL PLANT: Facility is unclean is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that the facility serves the clients a three (3) course meal: Breakfast is served between 7:30 a.m. - 9:00 a.m.; lunch is served between 12:00 noon - 1:00 p.m.; Dinner is served between 4:00 p.m. - 5:30 p.m. (LPA/RA observed the clients sitting in the dining area eating their breakfast upon arrival to the facility. LPA/RA toured the facility's commercial-size kitchen and observed a posted menu and perishable and non-perishable food supply. LPA/RA reviewed the facility's monthly menu that documented the meals served to clients that also includes snacks.) Facility staff and clients interviewed corroborated that the food service at the facility is adequate and if a client does not like something on the menu that the facility does serve an alternate meal.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of FOOD SERVICE: Inadequate food service is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed that facility staff receives in-service training annually. A review of the medication technicians training records documented medication verification training on 01/22/20, 11/19/21, 01/12/22, 05/12/22 on the topics of administering medications and document in the medication administration record, shadow destruction, receiving home health services, COVID-19 screening procedures,

NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200422141128

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: 08/30/2022

NARRATIVE

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infection control measurements, and reporting requirements. Facility staff and clients interviewed corroborated that the medication technicians administer the clients medications on time at 7:00 a.m., 12:00 noon, 3:00 p.m., and 7:00 p.m. If a client does not show up to the medication room for their med(s) then the med tech will call them over the intercom system or deliver it to the client(s) room. Housekeeping does a good job of keeping the clients rooms clean by doing their laundry, folding their clothes, and putting them away; make their beds and/or change and wash their bedding and linens; empty the trash cans and replenish the paper goods. Food service personnel prepare the clients daily meals to be served at 7:30 a.m., 12:00 noon, and 4:00 p.m. three (3) times a day.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of QUALIFICATIONS: Untrained staff is found to be UNSUBSTANTIATED.

Regarding Allegation #4: this investigation revealed that during the initial COVID-19 outbreak, facility staff was making sure that the clients were social distancing and wearing their mask. Facility had a set of COVID-19 protocols based on the Pasadena Health Department's guidelines. Facility staff and clients interviewed corroborated that facility staff would set up tables and chairs in various rooms and the clients were served meals during staggered times. (LPA/RA Ceniceros toured the rooms and took photos.) Facility staff would provide the clients with a mask(s) whenever the client requested for one and there was no charge to the clients.

Based on the evidence gathered and interviews conducted and records reviewed, 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 of OTHER: Facility not following COVID-19 guidelines is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Tricia Pedroza, Co-Owner/Acting Administrator.

NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022

LIC9099 (FAS) - (06/04)

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