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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 03/15/2024
Date Signed: 03/15/2024 12:41:28 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
08/22/2022 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220822124259
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: 48DATE:
03/15/2024
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Brenda Quiroz Diaz Lead MedTechTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident was sexually assaulted by an adult at the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sanjay Vaid conducted a subsequent complaint visit regarding the allegation and discuss the findings of the complaint investigation. LPA Vaid met with Lead Medtech, Brenda Quiroz Diaz, whom was filling in for the Assistant Administrator Estefany Lopez and discussed the purpose of the visit, which was to deliver complaint investigation findings.

The investigation consisted of the following: On 08/23/2022 LPA Wong toured the facility, conducted physical plant tour of the facility, and obtained staff and client roster and client #1 & #2 files for review.
On 09/22/22, the department conducted interviews with Assistant Administrator, Estafany Lopez. On 09/29/22, The department conducted interviews with client #1 (C1) and client #2 (C2). On 10/29/22 and again on 11/29/22, the department attempted to conduct interviews with C2’s home health staff, however, attempts were unsuccessful. On 10/10/22 and 10/12/22, the department contacted local law enforcement, Pasadena Police Dept to obtain records regarding suspected abuse of C1 and obtained the Police Report #2022-68519 on 10/14/22. (Continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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-20220822124259
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASA ALTA MANOR
FACILITY NUMBER: 198603295
VISIT DATE: 03/15/2024
NARRATIVE
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On todays visit, LPA interviewed client #3(C3) - #7(C7) and Administrator via telephone, and staff #3 (S3) – Staff #6 (S6) and toured the physical with lead MedTech Brenda Quiroz and LPA observed how staff interact with facility clients. LPA requested and obtained a copy of staff schedule and client roster, including a list of any clients receiving home health services.

Regarding allegation: resident was sexually assaulted by an adult at the facility. It is alleged that a client was sexually assaulted by staff of a third-party agency who was provide 24-hour care to the client’s roommate. Interviews with 2 of 7 clients revealed that staff from a third-party agency asked C1 for sexual favors with C2 witnessed, with the promise of buying C1 gifts in exchange for the sexual favors, On a subsequent interview, C1 denied being sexually abused by staff and did not recall the third-party agency staff sexually abusing C1. Interviews with 2 of 7 clients revealed the clients are not aware of any sexual allegation made between staff and clients. Interviews with Assistant Administrator revealed that staff were not aware of staff sexually abusing client in care and revealed facility staff self-reported an incident that occurred on or around 08/18/22, where C1 and C2 reported the third-party agency staff requesting sexual favor from C1 in exchange for gifts. Interview with 5 of 7 staff revealed not having knowledge of the incident. The department attempted to interview the staff from the third-party agency, however, attempts were unsuccessful. Local Law Enforcement conducted a visit to the facility on 08/18/22 and interviewed C1 & C2 and Assistant Administrator, Estefany Lopez, based upon the police report, the investigation revealed that the third-party agency staff denied having sexual relations with C1. Therefore, there is no evidence to support that facility staff were aware of an adult, including third party agency staff, having a sexual relationship and/or sexually abusing facility clients, including C1, and the facility staff self-reported the alleged sexual abuse.

Based upon records review and interviews conducted, the findings indicate that, 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 conducted with Lead MedTech Brenda Quiroz Diaz in-lieu of Assistant Admin Estefany Lopez. A copy of the licensing report was provided at time of visit.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2