<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603384
Report Date: 08/24/2025
Date Signed: 08/24/2025 09:28:28 AM

Substantiated


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
07/17/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250717082326
FACILITY NAME:PASADENA HIGHLANDSFACILITY NUMBER:
198603384
ADMINISTRATOR:KAY CANOFACILITY TYPE:
740
ADDRESS:1575 E WASHINGTON BLVDTELEPHONE:
(801) 815-0808
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:245CENSUS: 215DATE:
08/24/2025
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Cherry Castro Med- TechTIME COMPLETED:
09:35 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not answer resident's calls for assistance timely resulting in hospitalization
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Med-Tech Cherry Castro and explained the purpose of the visit. Administrator Kay Cano was notified by telephone.

The investigation consisted of the following: During the initial visit conducted on 07/22/2025, LPA toured the facility, interviewed Administrator, and obtained copies of the following documents: staff roster, resident roster, R1’s physicians reports, admission agreement, identification information (LIC 601), facility service plan, health and services evaluation results, meal orders, hospital discharge paperwork, medication list, and facility notes. During visit on 08/14/2025 LPA Gutierrez interviewed staff #1, interviewed staff# 2- Staff #4 by telephone, and residents #1-residents #6. On 08/22/2025 Staff five (S5) was interviewed over the telephone. During today’s visit LPA delivered findings.

See 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2025
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 6
Control Number 28-AS-20250717082326
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: 08/24/2025
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
In regard to the allegation” Staff did not answer resident's calls for assistance timely resulting in hospitalization”, It is alleged that staff failed to assist R1’s call for help from the pull cord resulting in R1 having to call 911 for themselves. During interview with Administrator, and staff five (5) out of six (6) stated that R1 pulled his/her pull cord and staff responded by knocking on R1’s door but did not enter room in fear of being yelled at by resident and not until paramedics arriving did, they know that R1 was having an emergency. During interviews with residents six (6) out of six (6) stated that staff may enter their room in case of an emergency with no problem. R1 stated that pull cord was used repeatedly and no staff came to assist resulting in 911 being called.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20250717082326
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2025
Section Cited
CCR
87468.2(a)(4)
1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
1
2
3
4
5
6
7
Administrator will conduct training on personal rights with staff and what to do when residents call for help with pull string and send LPA training log by POC due date.
8
9
10
11
12
13
14
This deficiency is evidenced by the following:'
R1 pulled on pull cord several times for assistance and staff failied to enter room resulting in R! having to call 911.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
07/17/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250717082326

FACILITY NAME:PASADENA HIGHLANDSFACILITY NUMBER:
198603384
ADMINISTRATOR:KAY CANOFACILITY TYPE:
740
ADDRESS:1575 E WASHINGTON BLVDTELEPHONE:
(801) 815-0808
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:245CENSUS: 215DATE:
08/24/2025
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Cherry Castro Med- TechTIME COMPLETED:
09:35 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not notice residents change in condition
Due to staff neglect, resident missed medications
Staff did not follow Physicians orders
Due to staff neglect, resident was not provided meals
Due to staff neglect, staff did not check on resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Med- Tech Cherry Castro and explained the purpose of the visit. Administrator Kay Cano was notified by telephone.

The investigation consisted of the following: During the initial visit conducted on 07/22/2025, LPA toured the facility, interviewed Administrator, and obtained copies of the following documents: staff roster, resident roster, R1’s physicians reports, admission agreement, identification information (LIC 601), facility service plan, health and services evaluation results, meal orders, hospital discharge paperwork, medication list, and facility notes. During visit on 08/14/2025 LPA Gutierrez interviewed staff #1, interviewed staff# 2- Staff #4 by telephone, and residents #1-residents #6. On 08/22/2025 staff five (S5) was interviewed by telephone. During today’s visit LPA delivered findings.

See 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20250717082326
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: 08/24/2025
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
In regard to the allegation “Staff did not notice residents change in condition”, it is alleged that staff failed to follow up on R1’s change of condition. During interviews with Administrator and staff six (6) out of six (6) stated that if staff notices a change of condition, it is reported immediately, and resident is observed. During document review it was revealed that R1’s vital signs and oxygen was checked and documented and R1 stated that they were feeling okay. During interviews with residents six (6) out of six (6) residents stated that if staff notices any changes they will come and check on them. R1 stated that med-tech checked on him/her and that they honestly felt better.

In regard to the allegation “Due to staff neglect, resident missed medications”, it is alleged that resident missed two medications due to staff neglect During interviews with Administrator and staff six (6) out of six (6) stated that all medications are given as prescribed. Administrator stated that R1 is in charge of their own medications and the facility does not hold medication for this particular resident however they provided medication services until R1 was feeling better. During that time staff noticed that at time of discharge from hospital R1 was given two new medications that R1 never picked up from pharmacy. During interviews with residents six (6) out of six (6) residents stated that they have never had any problems with medication at the facility. R1 stated that they are in charge of their own medications but did ask for assistance for a few days after hospital stay in which facility did provide.

In regard to the allegation “Staff did not follow Physicians orders”, it is alleged that staff gave resident a full dose of medication instead of half as prescribed. During interviews with Administrator and staff six (6) out of six (6) stated that medication is always given as prescribed. During interviews with residents two (2) out of six (6) residents stated that staff follows directions for all medications. Four (4) residents stated they don’t need help with medication management from staff.

In regard to the allegation “Due to staff neglect, resident was not provided meals”, it is alleged that staff failed to feed R1 upon return from hospital. During interviews with Administrator and staff six (6) out of six (6) stated that residents can always ask for meals if they are hungry. Administrator stated that R1 returned late from hospital and did not ask for a meal as a courtesy facility put R1 on tray service free of charge for three days. LPA obtained copy of meal service plan. During interviews with residents six (6) out of six (6) residents stated that they are always provided meals. R1 stated that he was feed dinner at hospital and upon return he/she was too tired to eat. R1 also stated that facility did provide tray services for three days.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20250717082326
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: 08/24/2025
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
In regard to the allegation “Due to staff neglect, staff did not check on resident”, it is alleged that staff did not know R1 had returned from hospital and did not check on R1. During interviews with Administrator and staff six (6) out of six (6) stated that anyone entering the facility needs to be checked in. Administrator stated there were notes that R1 returned in the evening and staff did check on R1. During interviews with residents four (4) out of six (6) residents stated that they have never retuned via ambulance. R1 stated that two staff checked on him/her the night they returned from hospital.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations 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. An exit interview was conducted, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6