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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603295
Report Date: 11/17/2021
Date Signed: 11/17/2021 03:10:00 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/15/2021 and conducted by Evaluator Joe Katrdzhyan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211115135025
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: 81DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Staff / Estefany Lopez
Facility Manager / Tricia Pedroza		TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not protect client's personal items.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nune Margaryan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPAs met with Staff / Estefany Lopez and were later joined by the Facility Manager / Tricia Pedroza who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Staff did not protect Client's personal items".

During today's visit, LPA conducted interviews with the Facility Manager, Staff 1 and 2 (S1 and S2) and Clients 1 and 2 (C1 and C2). Also, copies of the following documents were obtained in reviewed in reference to C1;
• Admission Agreement • Client Personal Property and Valuables Form • Client Face Sheet • Appraisal/Needs and Services Plan • Physician's Report

(Please see LIC 9099C for additional information)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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-20211115135025
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASA ALTA MANOR
FACILITY NUMBER: 198603295
VISIT DATE: 11/17/2021
NARRATIVE
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Allegation: Staff did not protect client's personal items. The details of this allegation stated that staff did not prevent the personal items of C1 (clothing, Nintendo and digital watch) from being stolen.
According to C1, the incident occurred on 11/12/21. Based on interviews conducted, there were no witnesses to the alleged incident. During the interview with C1, the statements obtained were inconsistent and changed during the course of the interview. C1 stated that the only item stolen from him was the Nintendo Switch. C1 did not mention anything about clothes or a digital watch being stolen from him. C1 stated that he purchased the Nintendo Switch from Best Buy about 2 -3 weeks ago (exact date unknown). C1 did not have a receipt for the purchase. Statements obtained from C1 and C2 (roommate of C1) stated that both clients do not lock their door preventing others from going inside their room. The items reported allegedly stolen were not listed on C1's Personal Property and Valuables form. Based on the interviews conducted and record reviews, there is insufficient evidence to support the allegation of "Staff did not protect client's personal items".

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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2