198603384-3-21-2025-28-AS-FFIS-DEZ2HQ-20250321172503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603384
Report Date: 03/21/2025
Date Signed: 03/21/2025 09:42:27 AM

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
02/19/2025 and conducted by Evaluator Sanjay Vaid

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250219084240

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: 223	DATE:	03/21/2025
		UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Kay Cano-Administrator		TIME COMPLETED:	08:34 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not adequately address a change in resident’s condition.
Staff did not inform resident's representative of incident(s) as required

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

**This is a subsequent visit to amend and supersede the reports dated 02/24/2025. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. **

On 02/24/2025, LPA Vaid conducted an Initial 10-Day complaint investigation regarding the above allegations. LPA was met by Adrienne Hurd-Assistant Executive Director. LPA discussed the purpose of the visit. LPA toured the facility with Adriene and did not observe any health and safety concerns. Investigation consisted of the following: interview of Staff #1 - Staff #7 (S1-S7); interviews of residents from resident#1-resident #10 (R1-R10); requested, obtained, and reviewed client #1 face sheet, admissions record, physicians report, preplacement appraisal, health services evaluation and service plan, mini-mental state examination. Staff roster and client roster.

Continued 809C.....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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 3

Control Number 28-AS-20250219084240

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: PASADENA HIGHLANDS	FACILITY NUMBER: 198603384
	VISIT DATE: 03/21/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

**This is a subsequent visit to amend and supersede the reports dated 02/24/2025. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. **

Regarding the allegation: Staff did not adequately address a change in resident’s condition. It is alleged that R1 is experiencing progressive behavioral expressions related to dementia and the facility is not addressing the changes in R1's condition and should have R1 placed in memory care or higher-level care facility. Seven (7) out of seven (7) staff interviewed denied this allegation. According to staff, R1 resides in assisted living program at the facility. Assistance is provided with housekeeping, medications, and daily living needs only, R1 is high functioning person and can comprehend and express their needs and concerns. Staff responsible for tracking change in health conditions are charting the residents’ health and medications changes and needs and are reporting to the residents POA/primary physician as needed. Progress notes are made by each caregiver/med tech that interacts with residents under their care. According to staff the POA have been provided other placement agencies that cater to dementia resident’s needs. Ten (10) out of ten (10) residents interviewed could not collaborate this allegation. According to couple of residents stated their needs and changes with their health conditions are communicated to their doctor, family and POA and they have not had any concerns with staff communicating their medical issues and needs. One resident stated, the caregivers have prevented serious health condition by informing their doctor and getting medical assistance right away. Other residents stated caregivers and med-techs are involved with our health and wellbeing. LPA attempted to interview R1’s personal caregiver/assistant hired by the R1’s POA, they declined. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Regarding the allegation: Staff did not inform resident's representative of incident(s) as required. It is alleged that the facility staff are not informing R1’s POA of incidents that happen with R1. Seven (7) out of seven (7) staff deny this allegation, staff state that resident’s behavioral are charted in the progress notes and communicated to the next staff- med-techs and caregivers, when residents fall ill, health conditions are communicated to responsible parties.

Continued on 809C...

SUPERVISOR'S NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20250219084240

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: PASADENA HIGHLANDS	FACILITY NUMBER: 198603384
	VISIT DATE: 03/21/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

**This is a subsequent visit to amend and supersede the reports dated 02/24/2025. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. **

Residents are sent to the Emergency room for precautions. Nine (9) out of ten (10) residents interviewed could not corroborate this allegation. According to interview conducted with R1’s POA, R1 was having an erratic episode with delusional behaviors in R1’s apartment and the staff did not do anything to stop the behaviors and redirect the resident until R1s POA notified the staff at the front desk. The staff did not notify resident’s POA of R1’s delusional episodes. According to R1, the reasons for R1’s erratic behavior was because R1’s personal property had been confiscated by the R1s’ POA, forcing R1 to purchase new communication devices and reinstate their digital profiles. R1 stated this ordeal was very disturbing for them. R1’s POA confirmed that R1s POA removed R1’s personal electronic devices without R1s approval. LPA attempted to interview R1’s personal hired assistant, they declined. According to R1 was due to R1s’ POA physically confronting R1s companion and angrily disapproved of R1s’ domestic partner and friend. Therefore, R1s POA was present during both of R1s behavioral episodes/incidents and upon staff knowledge of R1’s behavior/incidents, staff were present and assisted R1 by redirecting and attempting to calm R1. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview was conducted and report was provided to Kay Cano- Administrator.

SUPERVISOR'S NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3