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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 06/17/2023
Date Signed: 06/17/2023 01:43:52 PM

Substantiated


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
06/30/2022 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220630114339
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: 84DATE:
06/17/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Brenda Quiroz - Med-TechTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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This complaint was investigated by Licensing Program Analyst (LPA) Joe Katrdzhyan. Licensing Program Analyst (LPA) Luis Mora conducted an unannounced follow up visit to this facility to assist with delivering findings on the above-mentioned allegation of "Facility has bed bugs". Upon arriving at the facility, LPA met with Brenda Quiroz (Med-Tech) who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 7/5/22, in reference to the above-mentioned allegation. During the course of the investigation, interviews were conducted with various persons to include the Administrator, Staff members 1 through 3 (S1 - S3) and Clients 1 through 6 (C1 - C6). Also, invoice Records from Rhino Pest Control, Inc. were obtained and reviewed.

The investigation revealed the following: Allegation: Facility has bed bugs. Based on interviews conducted and record reviews, the statements obtained along with the information collected corroborated with the allegation of facility has bed bugs. (Continued LIC 9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023
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 5
Control Number 28-AS-20220630114339
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: 06/17/2023
NARRATIVE
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Statements obtained from staff and clients confirmed that Pasa Alta Manor has an ongoing issue with bed bugs and bed bugs were observed at the facility in Client 7’s (C7’s) room, just a few weeks prior to this complaint being reported to CCL. It was discovered that Rhino Pest Control, Inc. treats the facility twice a month for cockroaches but it’s facility staff who treat the facility for bed bugs by washing clothes, replacing mattresses and spraying client rooms. Invoice Records from Rhino Pest Control, Inc. for period 4/14/22 - 6/24/22 confirmed that Pasa Alta Manor is only being treated by the pest control company for cockroaches.

Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220630114339
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2023
Section Cited
CCR
80087(a)
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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

The requirement is not met as evidenced by:
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Administrator will maintain a contract with a licensed pest control extermination company for bed bugs and provide a written plan along with the contract to CCL outlining a revised approach to eradicate facility of bed bugs. POC must be submitted to CCL by the POC due date.
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Statements obtained from staff and clients confirmed that Pasa Alta Manor has an ongoing issue with bed bugs and bed bugs were observed at the facility in Client 7’s (C7’s) room, just a few weeks prior to this complaint being reported to CCL.
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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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/30/2022 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220630114339

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: 84DATE:
06/17/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Brenda Quiroz - Med-TechTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Residents are using illegal substances in the facility
INVESTIGATION FINDINGS:
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This complaint was investigated by Licensing Program Analyst (LPA) Joe Katrdzhyan. Licensing Program Analyst (LPA) Luis Mora conducted an unannounced follow up visit to this facility to assist with delivering findings on the above-mentioned allegation of "Residents are using illegal substances in the facility". Upon arriving at the facility, LPA met with Brenda Quiroz (Med-Tech) who assisted with the visit.

LPA Katrdzhyan conducted a prior visit to this facility on 7/5/22, in reference to the above-mentioned allegation. During the course of the investigation, interviews were conducted with various persons to include the Administrator, Staff members 1 through 3 (S1 - S3) and Clients 1 through 6 (C1 - C6).

The investigation revealed the following;
Allegation: Residents are using illegal substances in the facility. The details of this allegation states that Residents are using meth inside the facility.
(Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220630114339
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: 06/17/2023
NARRATIVE
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Based on interviews conducted, the statements obtained were inconsistent and did not corroborated with the above mentioned allegation. Staff and residents interviewed denied witnessing the use of meth on facility premises and confirmed the facility conducts random drug tests and room checks to help prevent such usage. The Administrator, explained that majority of the clients at the facility have a history of illegal drug usage and may use illegal substances while away from the premises, but random drug tests and room checks help prevent illegal substances from entering the facility and staff is diligent in preventing illegal drug usage within the facility. The Administrator stated that she has no knowledge of illegal drug usage at the facility nor has she been advised of such. Based on the investigation conducted, there is insufficient evidence to support the above-mentioned allegation to be true.

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.

An exit interview was conducted and a copy of this report was provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5