198603295-12-16-2025-28-AS-DSIS-DQ72T5-20260109164010

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 12/16/2025
Date Signed: 12/16/2025 02:59:59 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
12/12/2025 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251212081122

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:	12/16/2025
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Yensy Henriquez, Med Tech		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Staff do not safeguard resident's belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced initial 10-day visit to investigate the above allegation. LPA met with the Med Tech, Yensy Henriquez and discussed the purpose of today’s visit. LPA spoke with the Administrator over the phone and discussed the purpose of today’s visit.

During this investigation, LPA obtained a copy of the staff and client rosters. LPA interviewed the Administrator, Staff #1 (S1) to Staff #4 (S4), and Client #1 (C1) to Client #9 (C9). LPA obtained pertinent documents from C1’s file such as face sheet, Physician’s Report, Admissions Agreement, Appraisal/Needs and Services Plan, Client Personal Property and Valuables.

The investigation revealed the following: in regard to the allegation, “Staff do not safeguard resident's belongings.” It is alleged that S1 has been taking C1’s belongings such as clothing, shoes, body wash, and TV antenna. It is also alleged that S1 takes C1’s laundry and doesn't return it.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

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-20251212081122

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: 12/16/2025

NARRATIVE

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LPA interviewed C1 that corroborated with the allegation stating that belongings were missing and stolen by the staff and indicated the following items missing which included clothes, shirts, sweaters, sandals, pajamas, shoes, sandals, body wash, lotion, DVDs, CDs, bedspread, and blankets. C1 stated not being sure when this occurred but indicated S1 stole the belongings since S1 has the keys to C1’s room. However, C1 did not provide any evidence and did not witness S1 stealing the missing items and could not provide any witnesses that saw S1 steal C1’s belongings. LPA interviewed C1’s roommate, Client #2 (C2) that denied the allegation stating not witnessing C1’s belongings being stolen by S1 or any other staff. C2 also stated staff have not stole any of C2's own belongings. LPA interviewed an additional five (5) clients that denied the allegation stating that their belongings and items from their laundry have not been stolen by staff or gone missing. These additional five (5) clients also stated that they have not witnessed any staff stealing other clients’ belongings at the facility. LPA interviewed an additional two (2) clients that could not confirm nor deny the allegation as they stated their belongings were missing in the past but could not provide any evidence to confirm that the staff stole their belongings. LPA interviewed S1 that denied the allegation stated not stealing C1’s belongings. S1 also stated that when S1 is doing laundry and there is a report of missing items, the staff search and find the items. S1 stated when S1 does C1's laundry, S1 returns C1’s laundry. LPA interviewed the Administrator and three (3) additional staff denied the allegation stating that they have not stolen C1’s belongings. The Administrator and the three (3) additional staff stated they have not witnessed S1 or any staff stealing C1’s belongings. The Administrator and the three (3) additional staff also indicated not being reported of any missing items from C1’s laundry. The Administrator, S1, and one (1) out of the three (3) staff indicated that whenever C1’s room must be cleaned or staff must enter the room, the Administrator is contacted by staff and is directly involved to get C1 and C1’s family member’s approval. Per Administrator, whenever C1 reported belongings missing to the staff, the staff were able to find the items. LPA reviewed C1’s Appraisal/Needs and Services Plan dated 12/18/2025 indicate C1’s room is cluttered or messy and does not allow housekeeping to properly clean without C1’s approval. This Appraisal/Needs and Services Plan also indicates all closet clean outs are communicated and authorized by C1 and C1’s family member due to C1’s allegations in the past of things that C1 misplaced missing. Per Administrator, the police visited the facility twice on 12/12/2025 at 10am and between 4:30pm to 5:30pm but C1 was not present at both times of the visits and a police report was not provided. There is not enough sufficient evidence to substantiate.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20251212081122

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: 12/16/2025

NARRATIVE

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Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 was held, and a copy of this report was provided to the Med Tech, Yensy Henriquez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

LIC9099 (FAS) - (06/04)

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