198603384-5-22-2025-28-AS-WSHO-DK8VUD-20250804164435

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603384
Report Date: 05/22/2025
Date Signed: 05/22/2025 03:28:54 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
07/25/2024 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240725110705

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: 209	DATE:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Kay Cano		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in resident sustaining multiple falls and injuries
Staff performed an unsafe transfer resulting in resident sustaining an injury
Resident developed a pressure injury due to staff neglect
Resident’s condition worsened due to staff neglect
Staff isolated resident in her room

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced subsequent complaint investigation visit for the allegation listed above. LPA Trueman met with Administrator Kay Cano and the purpose of the visit was discussed.

At today's visit 05/22/24 LPA has completed the following: LPA collected a copy of the staff and resident roster, LPA Interviewed Staff #1- #2 (S1-S2) and Residents #2 - #8 (R2-R8). LPA reviewed Resident R1's file and the facility submitted the Physician's Report, Emergency ID, Special Incident Report's (SIR's) and Pre-placement Appraisal.
Documentation from the primary care doctor, and documentation from Huntington Health Hospital were also submitted.
The investigation revealed the following:
In regards to the allegation Staff did not provide adequate supervision resulting in resident sustaining multiple falls and injuries, based on interviews conducted and information gathered it was revealed by

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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-20240725110705

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: PASADENA HIGHLANDS	FACILITY NUMBER: 198603384
	VISIT DATE: 05/22/2025

NARRATIVE

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3 out of 7 residents who stated that they had a fall and staff responded right away and paramedics were also here quickly. 4 residents had not had a fall or seen anyone have a fall.
Staff interviewed stated that Resident R1 had an assist to ground and not falls.
Stated that 2 caregivers were needed and only 1 time there was a slight fall when 2 caregivers were providing assistance in a sit to stand chair and Resident R1 caught her feet under the chair and slid back and hit her head and had slight abrasion on right hip.
Administrator documented specific dates in which assist to ground was done during transfer:
01/07/24- Resident R1 fell to knees with no injury.
04/11/24- Assist to ground no injury.
06/05/21- Assist to ground no injury.
06/26/24- Assist to ground no injury.
07/02/24- With staff and slipped from shower chair
07/21/24- Transfer with 2 staff with foot stuck under the chair causing Resident R1 to slide to to the floor.
Administrator stated that staff were always assisting Resident R1 with transfers and that they were not falls. Stated that they were assist to ground.
Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24
6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24.
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.

In regards to the allegation Staff performed an unsafe transfer resulting in resident sustaining an injury, based on interviews conducted and information gathered it was revealed that 3 of 7 residents had needed a transfer and stated that staff did a good job. 4 residents stated that the staff are never neglectful.
Staff stated that Resident R1 needed assistance by 2 caregivers and only had 1 incident in which Resident R1 caught her feet under the chair and slid back and hit her head and had slight abrasion on right hip.
Stated Resident R1 was never neglected and the facility responded right away sending Resident R1 to the hospital.
Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24
6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24.
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.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20240725110705

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: PASADENA HIGHLANDS	FACILITY NUMBER: 198603384
	VISIT DATE: 05/22/2025

NARRATIVE

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In regards to the allegation Resident developed a pressure injury due to staff neglect, it was revealed in hospital documentation from Huntington Health that Resident R1 was seen on 07/21/24 and it's noted
bilateral heels not a pressure injury.
Right hip listed as abrasion.
Buttocks, groin- erychema not a pressure injury.
Resident's 2-8 stated that they never had a pressure injury and do not know of any residents who do.
Staff stated that hospital notes show no pressure injuries.
Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24
6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24.
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.

In regards to the allegation Resident’s condition worsened due to staff neglect, based on interviews conducted and information gathered Resident's R2- R8 stated that staff have been great at assisting them and their condition has never worsened.
Staff stated that in regards to Resident R1 she was seen every hour.
Also stated that Resident R1 was seen weekly by the primary care physician.
Stated that some medication Resident R1 was taking can lead to bruising.
In addition with 2 caregivers assisting they have to hold Resident R1 tight so not to fall to the ground which could lead to slight bruising.
Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24
6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24.
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.

In regards to the allegation Staff isolated resident in her room, based on interviews conducted and information gathered Resident's R2- R8 all stated that staff will check on them daily and are never neglectful.
Stated that if not in their room staff will assist if needed at dining room or other areas in the facility.
Staff stated that Resident R1 would get visits hourly for assistance for Resident R1 and her spouse.
Also stated they would go to their room constantly to reposition so they could prevent any sores from occurring.

It should be noted that the last day Resident R1 resided at the facility was 07/21/24.

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.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

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