198603384-7-13-2023-28-AS-RORN-CU5QUU-20230727122919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603384
Report Date: 07/13/2023
Date Signed: 07/13/2023 02:18:11 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
10/11/2021 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211011093000

FACILITY NAME:	PASADENA HIGHLANDS		FACILITY NUMBER:	198603384
ADMINISTRATOR:	CANO, KAY		FACILITY TYPE:	740
ADDRESS:	1575 E WASHINGTON BLVD		TELEPHONE:	(801) 815-0808
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	245	CENSUS: 164	DATE:	07/13/2023
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Kay Cano - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff is not providing adequate care and supervision to a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit to the facility listed above to deliver findings on the above-mentioned allegation of "Staff is not providing adequate care and supervision to a resident". Upon arriving at the facility, LPA met with Administrator Kay Cano and the reason for the visit was explained.

The investigation consisted of the following: On 10/20/2021 LPA Alma Gonzalez conducted an interview with Executive Director Brodey De Borde, Health and Wellness Director Laura Sanchez at 2:15pm, R1's Private Caregiver, reviewed R1's facility file and collected copies of the following documents: Physician's Report, Hospice agency physician's orders and obtained copies of Staff and Residents Rosters • Physicians Report for R1 • Hospice Records • R1 Medication List

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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-20211011093000

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: 07/13/2023

NARRATIVE

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• Death Certificate • Physician Orders for Life-Sustaining Treatment for R1 • Appraisal Needs and Service Plan for R1. LPA also conducted interviews with Administrator Kay Cano, S1-S5, and R2-R8.

The investigation revealed the following:
Allegation: Staff is not providing adequate care and supervision to a resident. The details of this allegation states that R1 was denied care and private caregiver was not allowed to administer medication. Based on interviews conducted the statements obtained all denied above allegation. Interviews with Administrator Kay Cano and S1-S5 revealed that R1 caregiver was able to administer medication until it came to the attention of the facility that R1 was no longer able to manage own treatment/medication/equipment, therefore, per facility procedures, regulations, and meeting of Title 22 regulations the facility placed R1 on medication management. Based on file review MedTechs at the facility have proper certifications and on going training for medication administration. In regards to the facility not providing adequate care and supervision to resident, interviews with R2-R8 all denied allegation. All interviews with residents were consistent and stated they receive proper care when or if needed and feel confident that the facility provides that care to all residents.

Based on the information gathered, there is insufficient evidence to support the above allegation to be true.

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 to Administrator Kay Cano.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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