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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:10:22 PM

Substantiated


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
12/31/2021 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211231085835
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: 78DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Tricia Pedroza, Co-Owner/Acting AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident was physically assaulted by another resident at the facility.
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 allegation. An initial 10-Day visit was conducted by LPA Joe Katrdzhyan on 01/06/22 with Staff #1 (A2) Estefany Lopez, Assistant Administrator. LPA/RA interviewed (between 12:15 p.m. - 1:00 p.m.) two (2) staff members and Resident #1; as (former) Resident #2 relocated to a higher level of care. LPA/RA Ceniceros reviewed (between 1:00 p.m. - 1:30 p.m.) pertinent documents: Admissions Agreement, Emergency I.D. and Information, Physician’s Report, Appraisal/Needs & Services Plan, and Functional Capability Assessment
Substantiated
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-20211231085835
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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for Resident #1 and (former) Resident #2; Facility Staff & Residents' Rosters, Unusual Incident/Injury Reports (dated 12/28/21 and 12/29/21) with Administrator Self-reported SOC 341 (dated 12/28/21), and Pasadena Police Department Report & SOC 341 (dated 12/28/21).

Regarding Allegation #1: this investigation revealed that local law enforcement responded to the facilityregarding an aggressive act to another client that occurred on 12/27/21 (approximately) 10:00 p.m. The incident was captured on surveillance video. Client #1 was standing in the common area watching a movie and Client #2 told the client to go outside. Client #1 declined and Client #2 began to mumble then without hesitation punched Client #1 in the face (using a closed right fist) and caused a laceration to Client #1's lip. Client #1 stated that an attempt to look for a staff member after the incident happened, the client was unable to locate anyone. Client #1 waited until the next morning (12/28/21) and told the Asst. Administrator (A2) Estefany Lopez. A2 stated that Client #1 came to her in the morning of 12/28/21 and told her of the incident. A2 administered first aid to Client #1's lip. A2 spoke to Client #2 who admitted to punching Client #1 in the face. A2 contacted local law enforcement and showed them the surveillance footage of the incident. Resident #2 was released on a misdemeanor citation and was later moved to a higher level of care facility. Co-Owner/Acting Administrator, Tricia Pedroza made all the appropriate notifications to the allied agencies (via LIC 624 and SOC 341) on 12/28/21.

Based on the evidence gathered, surveillance video footage, interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident was physically assaulted by another resident at the facility is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency was observed and citation issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were 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)
Page: 2 of 3
Control Number 28-AS-20211231085835
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2022
Section Cited
CCR
85078(a)(1)
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Responsibility for Providing Care & Supervision
(a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Licensee/Administrator shall read Title 22, Section "Responsibility for Providing Care & Supervision" and send a written statement to CCLD by the POC date that the facility will ensure that staffing is available to meet the client(s) needs. Please submit POC to CCLD no later than 09/13/22.
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(Cont) Following an incident that occurred on 12/27/21 (approximately) 10:00 p.m. Client #1 attempted to look for a staff member; and, the client was unable to locate anyone. Client #1 then waited until the next morning (12/28/21) to report the incident to Asst. Administrator (A2: Estefany Lopez).
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3