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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 12/16/2022
Date Signed: 12/16/2022 04:11:14 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
12/12/2022 and conducted by Evaluator Jewel Baptiste
COMPLAINT CONTROL NUMBER: 28-AS-20221212124136
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: 83DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Tricia Pedroza AdministratorTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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9
Resident was asked to work at the facility
INVESTIGATION FINDINGS:
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 On 12/16/22 at 1:29 p.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Tricia Pedroza (Administrator) and explained the purpose of the visit.

During today’s visit LPA and administrator toured the facility. LPA obtained resident/ staff roster, Resident #10 and Resident #11 Needs and service plan and house rules. Day program will email LPA plan for clients in chore program on 12/19/22. LPA also interviewed: Administrator and a total of two (2) staff who shall be referred to as S1, and S2. LPA also interviewed day program staff, who will be referred to as S3. LPA interviewed a total of 9 residents who shall be referred to as: R1 through R9.

Report continued 9099c
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
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-20221212124136
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: 12/16/2022
NARRATIVE
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The investigation reveals the following: Regarding "Resident was asked to work at the facility ", it is alleged that the facility is asking residents to clean restrooms and assist in the dining room area. During the tour LPA did not observe residents working in the facility. The administrator stated that no resident is forced to work in the facility. The residents attend a day program called Integrated Health Care Options and they participate in community service and a chore program that allows them to get monetary incentives for their services. 2/2 staff denied the allegation citing that residents are not required to work at the facility. Interview with the day program staff stated the program do not force residents to work but encourage them to participate. Some of the residents in the program don’t work but has to control their hygiene to receive monetary incentives because they program try to encourage independence. If the resident does not want to participate, they will not be forced. 9/9 residents stated they are not required to work, and working is a program offered by the day program and not the facility. 2/9 residents state they do attended the day program and enjoys working because they like receiving monetary incentives. LPA reviewed R10 and R11 needs and service plan and it outline the chores residents they are capable of completing and the chemicals they are able to handle.

Based on LPA's observation, interviews and file review the 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 allegations are UNSUBSTANTIATED.

Exit interview conducted with Tricia Pedroza and a copy of this record provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
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