198603295-5-8-2023-28-AS-MVAO-CRUNBJ-20230515101910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 05/08/2023
Date Signed: 05/08/2023 01:13:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/12/2021 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210812153547

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: 87	DATE:	05/08/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Tricia Pedroza		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not administer residents medication
Staff took residents clothing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent complaint visit to deliver investigation findings for the above stated allegations. LPA met with Administrator Tricia Pedroza and explained the reason for the visit.

The investigation consisted of: During the initial visit conducted on 08/19/21, LPA conducted an interview with Administrator Tricia Pedroza, S1-3, and C1. LPA obtained copies of Staff and Client Rosters. LPA reviewed C1's facility file and collected copies of documents pertinent to the investigation. LPA additionally reviewed Medication Administration Records (MARs) and collected copies of MARs for July - August 2021 for C1-C8 . On 05/08/23, LPA interviewed Administrator Tricia Pedroza, S4 and C9-15. LPA collected copies of Staff and Client Rosters. LPA additionally conducted a tour of facility which included observations of common areas, dining room, and medication room.

(See LIC9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210812153547

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASA ALTA MANOR	FACILITY NUMBER: 198603295
	VISIT DATE: 05/08/2023

NARRATIVE

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Investigation revealed the following: Regarding allegation, Staff did not administer residents medication, it is alleged that facility staff did not give a facility client their medications during the day which resulted in the client not feeling well the next day. Interviews conducted with Administrator Tricia Pedroza and S1 revealed that all clients are given their medications as prescribed by their doctor. They stated that once staff give the clients their medications staff then complete and fill out each client's MAR each time a dose is given. They stated that if a client refuses to take their medications it is properly documented and also reported to the client's doctor as well as Community Care Licensing Division (CCLD) and any other applicable agencies. They stated that they are not aware of any facility client not feeling well due to not taking their medications for a whole day. Interviews conducted with 7 out of 8 clients revealed that they do not have any concerns with medication administration and stated that they get their medications timely every day. 1 client stated that they do get their medications every day but they missed their medications three times due to being asleep but that staff did bring the medications to their room. 7 out of 8 clients stated that they are satisfied with the services that they receive at the facility. LPA reviewed C1-8 MARs and did not observe anything that is of concern. MARs were properly completed with staffs initials for each client. LPA's observations of facility medication room did not reveal anything of concern. Based on LPA review of documents and statements gathered from interviews conducted with staff and clients there was not enough supportive evidence to concur with the reported allegation.

For allegation, Staff took residents clothing, it is alleged that staff took all client's clothing away and the client was only left with the clothes that they were wearing. It is also alleged that certain staff take client's clothing. Interviews conducted Administrator Pedroza and S2-4 revealed that staff only collect clothing that clients want washed. They stated that each client has a scheduled laundry day which is done once a week. Laundry day is for clothes and also for linens and bedding. They also stated that there is one client that requires their laundry to be done more than once per week due to accidents that the client has. They stated that the client will go out at times to do their own laundry because they do not want staff to see the state of their clothing. Facility staff denied taking any clients clothing and not returning it. Staff stated that once the client's clothing is washed it is returned to them. Interviews conducted with 6 out of 8 clients revealed that they are satisfied with the laundry service that the facility provides and stated that they do not have any concerns. 1 client stated that they like to go out and do their own laundry due to preferences of laundry machines. 1 client stated that staff have expressed to them that they want to throw the client's clothes away due to the client soiling their clothes. 7 out of 8 clients stated that they are satisfied with the services that they

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210812153547

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASA ALTA MANOR	FACILITY NUMBER: 198603295
	VISIT DATE: 05/08/2023

NARRATIVE

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receive at the facility. Based on statements gathered from interviews conducted with staff and clients there was not enough supportive evidence to concur with the reported allegation.

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.

Exit interview held. A copy of the report was provided to Administrator Tricia Pedroza.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023

LIC9099 (FAS) - (06/04)

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