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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603384
Report Date: 08/31/2022
Date Signed: 08/31/2022 04:20:16 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
08/24/2022 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20220824103857
FACILITY NAME:PASADENA HIGHLANDSFACILITY NUMBER:
198603384
ADMINISTRATOR:DEBORDE, BRODYFACILITY TYPE:
740
ADDRESS:1575 E WASHINGTON BLVDTELEPHONE:
(801) 815-0808
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:245CENSUS: 162DATE:
08/31/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Brodey DeBorde, administratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide resident's records to the authorized representative upon written request.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegation listed above. During today’s visit, LPA met with Administrator, Brodey DeBorde. LPA explained the purpose of today's visit.

The investigation consisted of the following: LPA interviewed resident #1, staff from staff#1 to staff#4 and reviewed records. LPA obtained copies of resident roster, staff roster, document request (2 pages), dated 8/18/22 (FedEx), document request (Electronic mail) dated 8/31/22 (5 pages) with Power of attorney.

In regard to allegation "facility staff did not provide resident's records to the authorized representative upon written request," it was alleged that facility did not provide the requested document to resident#1’s attorney on a timely basis. LPA interviewed Administrator and staff. Staff interviews revealed four (4) out of four (4) staff denied the allegation. Staff#3 and facility record reviews revealed that document request dated 8/18/22 did not provide authorization or power of attorney along with the request. It would be a HIPPA violation to provide document without authorization. (-continued in LIC 89099C-)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
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 2
Control Number 28-AS-20220824103857
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: 08/31/2022
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
On 8/31/22, an updated document request dated 8/31/22 along with authorization was provided to facility. Per staff interviews, facility will provide requested document per request dated 8/31/22 accordingly. Therefore, facility did not fail to provide resident’s records to the authorized representative.

Although the allegation may have happened or is valid, there’s not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED

Exit interview conducted and copy of LIC 9099 report was given to administrator.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2