198603295-1-28-2026-28-AS-DSIS-DQWVCU-20260202151939

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 01/28/2026
Date Signed: 01/28/2026 03:15:27 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
01/26/2026 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260126143427

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: 85	DATE:	01/28/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Estefany Lopez, Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff did not prevent a client from hitting another client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced initial 10-day complaint visit at the facility and met with the Administrator, Estefany Lopez to discuss the purpose for today's visit. The purpose of the visit is to investigate the above allegation.

Investigation consisted of the following: LPA requested a copy of staff and client rosters. LPA also requested copies from Client#1 (C1) and Client #2 (C2’s) files such as: Face Sheet, Physician’s Report, House Rules, Appraisal/Needs and Services Plan, Personal Rights and other pertinent documents. LPA also obtained Staff training documents. LPA interviewed C1, Client #3 (C3) to Client #10 (C10), the Administrator, and Staff #1 (S1) to Staff #4 (S4). LPA attempted to interview C2 but C2 refused to be interviewed.

The investigation revealed the following: In regards to the allegation, “Staff did not prevent a physical altercation between residents in care.” It is alleged that C1 was hit in the face by C2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

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-20260126143427

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: 01/28/2026

NARRATIVE

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It is also alleged that C1 did not provoke the C2 to get his in the face and that C2 was saying racist comments towards C1, got too close and C2 ended up punching C1 in the face. LPA interviewed one (1) staff that denied the allegation stating on witnessing the incident on 01/17/2026 by hearing a noise of a slap and immediately intervened the physical altercation by de-escalating and separating both C1 and C2. One (1) staff observed the right side of C1’s cheek was red and LPA reviewed LPA reviewed the shift notes dated 01/17/2026 that had a photo of C1’s face. Per Administrator, C1 was provided by staff an ice pack for the red mark on C1's face at the time of the incident. LPA also reviewed SIR (Special Incident Report) that on 01/17/2026, C1 had a physical altercation with another client and refused medical treatment at the time of the incident and did not wish to contact law enforcement. LPA interviewed the Administrator, and an additional three (3) out of three (3) staff that all denied the allegation stated not witnessing the physical altercation between C1 and C2 on 01/17/2026 but stated that whenever clients are involved in a physical altercation, the staff immediately intervene, separate, and re-direct the clients. LPA interviewed C1 that denied the allegation stating that there was a verbal and physical altercation between C1 and C2 and that both clients were yelling at each other but staff immediately intervened and de-escalated the situation by separating both C1 and C2. C1 also stated sustaining a red mark on right cheek so C1 received an ice pack by the staff to apply on C1’s face but refused further medical treatment at the time of the incident and did not wish to contact law enforcement. LPA attempted to interview C2 but C2 refused to be interviewed. LPA interviewed an additional eight (8) out of eight (8) clients who denied the allegation by stating not witnessing the physical altercation between both C1 and C2 that occurred on 01/17/2026. However, six (6) out of eight (8) clients stated that staff immediately intervene and de-escalate verbal or physical altercations by separating the clients. Two (2) out of eight (8) clients stated that they have not witnessed any physical or verbal altercations at the facility. Eight (8) out of eight (8) clients also stated feeling safe at the facility. LPA reviewed ongoing staff training in-services on Mandated Reporting and Resident Rights in file. There was insufficient evidence to corroborate with the allegation.

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 Administrator, Estefany Lopez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC9099 (FAS) - (06/04)

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