198603384-3-27-2023-28-AS-RORN-CQCSSH-20230328140758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603384
Report Date: 01/30/2023
Date Signed: 03/27/2023 08:42:42 PM

Unsubstantiated

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
01/23/2023 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230123161153

FACILITY NAME:	PASADENA HIGHLANDS		FACILITY NUMBER:	198603384
ADMINISTRATOR:	KAY CANO		FACILITY TYPE:	740
ADDRESS:	1575 E WASHINGTON BLVD		TELEPHONE:	(801) 815-0808
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	245	CENSUS: 59	DATE:	01/30/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Executive Director, Kay Cano		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to a resident while in care.

INVESTIGATION FINDINGS:

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***This report serves as an amendment and supersedes the original complaint investigation report created on 01/30/2023. This report is being amended to add additional information and statements. No other changes have been made to the report. Investigation findings on this report remain the same. ****

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced 10-day initial complaint visit regarding the above stated allegation. LPA met with Kay Cano, Executive Director and explained the reason for the visit.

The investigation consisted of the following: LPA reviewed and obtained copies of Staff & Resident Rosters, Staff schedule, Facility's elopement/missing resident policy, Resident #1 (R1) files such as: Physician's Reports (2/07/2020 & 1/05/2023), Health & Services Plan, Residence and Care Agreement, and Incident Report. LPA interviewed Resident #1 (R1) - Resident #6 (R6) and Staff #1 (S1) - Staff #6 (S6).

The investigation revealed the following: in regards to the allegation “Staff did not provide adequate supervision to a resident while in care”, it is alleged that on 01/21/2023, R1 was gone missing. R1 was last seen with her husband, on the fourth floor at approximately 9:30 a.m. and husband reported to the front desk that R1 was missing. *******REPORT CONTINUED ON LIC9099-C******

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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-20230123161153

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: PASADENA HIGHLANDS	FACILITY NUMBER: 198603384
	VISIT DATE: 01/30/2023

NARRATIVE

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*****This report serves as an amendment and supersedes the original complaint investigation report created on 01/30/2023. This report is being amended to add additional information and statements. No other changes have been made to the report. Investigation findings on this report remain the same. ******

6 out of 6 staff members interviewed denied the allegation and stated that they conduct routine safety checks to residents. Staff members interviewed indicated they monitor all residents including R1 and provide assistance & supervision in the facility during their work shifts. Staff members also indicated that there are cameras in the common areas as well as in and out of the building which were operational. S1 stated that she always ensures that the facility is fully staffed to meet the needs of the residents. S1 stated that R1 is high functioning and does not have a 1:1 care. LPA reviewed R1's assessment on 01/05/2023 which revealed Dementia as secondary diagnosis and was recommended for higher level of care and services. S1-S2 stated that there is always someone in the front desk to monitor as that is where the residents pass when exiting the facility. S2 stated that after R1 was reported missing, a staff member called code ‘green’ which means 'elopement/wandered away' over the radio. A thorough search was immediately done by all staff. R1 was not found after 15 minutes, so the staff called the local police department to report, following the facility’s procedure. Staff members interviewed stated that they are all aware that R1 needs reminder and requires higher supervision. Staff also redirect R1 sometimes, however R1 refused to listen to staff. Staff also indicated that R1 can walk fine and has the right to leave the property if she wants to. R1 does not have a 1:1 caregiver and shares a room with her husband. 6 out of 6 residents interviewed denied the allegation. 3 out of the 6 residents interviewed indicated they were not aware of this incident. Residents interviewed indicated that they feel there is sufficient staff to provide adequate supervision and monitoring to meet their needs. R2 stated that he stays on and watch R1 24/7 and does not let R1 out of his sight. Residents interviewed indicated that they feel safe and comfortable at this facility. LPA observed the Facility exit doors and there was no exit door near R1's apartment. The facility also has video surveillance in the common areas for additional supervision. LPA also reviewed facility schedule and observed that there is enough staff on schedule to properly oversee residents and meet their needs. Therefore, there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, the findings indicate that the staff provided adequate supervision to R1 while in care. 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.

Exit interview held, and a copy of this report was provided to Kay Cano, Executive Director.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC9099 (FAS) - (06/04)

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