Pasadena Villa Senior Living

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit regarding the above mentioned allegation. LPA met with Administrator, Bryanna Luke and explained the purpose of the visit. This investigation was conducted by Investigator Santana with the Investigations Branch and consisted of the following: On 08/21/2025 and 09/15/2025, LPA Pena conducted a tour of facility and common areas, obtained a copy of the Staff and Resident rosters, Facility sketch, House rules, Home Health Notes, pertinent files for Resident #1 (R1) - Resident #2 (R2), Unusual Injury/Incident Reports (May - Aug 2025), Nurse's Notes, SOC341 (08/21/2025), R1’s hospital discharge records and Pasadena Police Dept report #2025-65144. During today's visit, LPA obtained a copy of the Staff and Resident rosters, delivered findings and issued a separate Case Management-Deficiencies. ******CONTINUED ON LIC9099-C***** UnsubstantiatedRead the full finding— CDSS inspection report, October 24, 2025 · control 28-AS-20250820145116

Licensing Program Analyst (LPA) Daniel Konishi conducted a unannounced 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator, Bryanna Luke. The investigation consisted of the following: LPA reviewed and requested copies of Resident #1 (R1) file documents such as Face Sheet, Physician's Report, Appraisal Services and Needs Plan. LPA also obtained the Staff & Resident Roster, and staff in-service training document. LPA also interviewed Resident #1 (R1) to Resident #6 (R6), the Administrator, and Staff #1 (S1) to Staff #4 (S4). The investigation revealed the following: in regard to the allegation "Resident was not accorded dignity during an interaction with staff while in care", it is alleged that on 10/16/2025, S1 entered R1’s bedroom and pressed R1’s body in bed by climbing on top of R1 and put S1’s weight on R1 pressing hard on R1’s hip while reaching for R1’s controller that fell on the floor. UnsubstantiatedRead the full finding— CDSS inspection report, October 23, 2025 · control 28-AS-20251020094420

Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Administrator, Bryanna Luke. On 09/02/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA reviewed and requested copies of Resident #2 (R2), Resident #3 (R3), Resident #4 (R4's) file documents such as Face Sheet, Physician's Report, Admission Agreement, Appraisal Services and Needs Plan, House Rules, Personal Rights. LPA also obtained the Staff & Resident Roster, and staff in-service training document. LPA also interviewed Resident #1 (R1) to Resident #8 (R8), the Administrator, and Staff #1 (S1) to Staff #4 (S4). On 09/15/2025, LPA obtained Special Incident Reports dated 08/28/2025 and 08/30/25 from the Administrator by fax. UnsubstantiatedRead the full finding— CDSS inspection report, September 19, 2025 · control 28-AS-20250827141339

Licensing Program Analyst (LPA) Bennette Penai conducted a subsequent complaint visit regarding the above allegation. LPA discussed the purpose of the visit with Administrator, Bryanna Luke. The investigation consisted of the following: On 08/21/2025, LPA conducted a tour of facility and common areas and obtained a copy of the Staff and Resident rosters, facility sketch, pertinent files for Resident #1 (R1) - Resident #2 (R2), Unusual Injury/Incident Reports (SIR) (May - Aug 2025). Administrator provided a copy of the completed SOC341 (dated 08/21/2025) and Pasadena Police Dept report #2025-65144. LPA also requested House rules, Home Health Notes and Nurse's Notes for R1-R2. During today's visit, LPA obtained a copy of the Staff and Resident rosters, Unusual Injury/Incident Reports (July-Aug 2025) for R1 and reviewed pertinent files for R1 including nurses notes and hospital discharge records. LPA also interviewed Staff #1 (S1) - Staff #4 (S4) and Resident #2 (R2) - Resident #10 (R10).Read the full finding— CDSS inspection report, September 15, 2025 · control 28-AS-20250820145116

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Facility staff did not prevent residents from engaging in a physical altercation". Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan conducted a prior visit to this facility on 10/27/21, in reference to the allegation listed above. During the course of the investigation, LPA conducted interviews of various persons to include the Assistant Administrator, Staff members 1 - 3 (S1 - S3) and Residents 1 - 4 (R1 - R4). LPA also reviewed the surveillance video regarding the incident involving Residents 1 and 2 (R1) and (R2). The investigation revealed the following; The incident involving R1 and R2 occurred on 10/20/21, at approximately 2:30pm. Based on interviews conducted, R2, who is visually impaired was observed by witnesses yelling in the lobby, nRead the full finding— CDSS inspection report, December 14, 2021 · control 28-AS-20211021085901

Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Alex Solorio and explained the reason for the visit. The initial complaint visit was conducted by LPA Rivas on 5/13/20. The investigation consisted of the following: LPA Rivas interviewed one staff member, Resident #1 (R1), and R1's Service Coordinator. LPA Vasallo obtained R1's records including face sheet, physician's report dated 3/20/20, and medication list. LPA Vasallo also interviewed six residents and two staff. The investigation revealed the following: Allegation Staff took away resident's personal property. It's alleged staff took R1's cellphone. R1 was interviewed and indicated staff took his/her cellphone. Staff interviewed denied the allegation. Staff indicated R1 would misplace his/her belongings and would find it a short time later. Staff confirmed R1 had a "flip phone" and would use it often. Residents interviewRead the full finding— CDSS inspection report, December 2, 2021 · control 28-AS-20200506135045

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent complaint visit to the facility and was greeted by Assistant Administrator Alexander Solorio and explained the reason for the visit. The purpose of the visit is to deliver the findings for the above allegations. Initial visit was conducted on 12/17/2020 and interview was conducted with Wellness Nurse / Marisol Cruz Riquelme telephonically due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). Subsequent visits were conducted on 7/21/21 and 9/9/21 in which staff and resident's were interviewed. Investigation consisted of interviews with staff, residents, hospice agency representative, social worker for Resident 1, and review of Hospice Documentation. In regards to the allegation Staff neglected resident, based on interviews conducted and information gathered it was revealed that Resident 1 was admitted to the facility on 12/01/20. Hospice agency began service on 12/02/20 for Resident 1 whichRead the full finding— CDSS inspection report, November 23, 2021 · control 28-AS-20201210170802

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit regarding the above allegation. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: On 04/14/21, LPA Joe Katrdzhyan conducted an initial complaint investigation via telephone due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). Today's visit: LPA Luis Mora obtained copies of staff & client rosters, call light & response time in-service training signing in sheet, and medication records for Resident #1 - Resident #7 (R1-R7). LPA also interviewed Resident #1 - Resident #7 (R1-R7) and Staff #1 - #5 (S1-S5), and toured facility. The investigation revealed the following: it's alleged that staff are not administering the medication in a timely manner. Based on interviews conducted with residents, 7 out of 7 stated that they get their medication on time and have had no issues receiving their medication.Read the full finding— CDSS inspection report, October 20, 2021 · control 28-AS-20210407154550

Licensing Program Analysts (LPAs) Luis Mora and Joe Katrdzhyan conducted an unannounced complaint visit regarding the above allegations. LPAs met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: LPAs obtained copies of Staff & Client Rosters, Staff #1 - #5 (S1-S5) New Hire Initial Training Record sheet and Hands-on Training Record sheet. LPA Mora interviewed Assistant Administrator Alexander Solorio and S1 - S5. The investigation revealed the following: in regards to the allegation "facility made false claims regarding employee training.", it is alleged that the assistant administrator Alexander Solorio signed caregivers training certificates, however, the caregivers never actually received the training. LPA Mora observed CPR/First Aid certificates for S1 - S5. (CONTINUED ON LIC 9099C) UnsubstantiatedRead the full finding— CDSS inspection report, October 6, 2021 · control 28-AS-20201201103928

Licensing Program Analysts (LPAs) Joe Katrdzhyan and Luis Mora conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPAs met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Resident was sexually abused while in care". During today's visit, LPA conducted interviews of various persons to include the Assistant Administrator, Residents 1 through 3 (R1 - R3) and Staff #1. LPA attempted to interview Staff 2 via telephone but was unsuccessful. The investigation revealed the following; Allegation: Resident was sexually abused while in care. The details of this allegation states that on 9/9/21, R1 was sexually assaulted by R2, while she lay in her bed. (Please see LIC 9099C for additional information) UnsubstantiatedRead the full finding— CDSS inspection report, September 21, 2021 · control 28-AS-20210920110503

Licensing Program Analysts (LPAs) Nune Margaryan and Joe Katrdzhyan conducted a subsequent visit to the facility to further investigate the above noted allegation. Upon arriving at the facility, LPAs met with Administrator Alexander Solorio and explained the purpose of this visit. The initial visit was conducted by LPAs Nune Margaryan and Tony Vasallo on 08/11/21. During the visit, LPAs obtained resident and staff roster, interviewed six (6) residents and six (6) staff. Resident #1's (R1) file was reviewed. On a later date additional phone interviews were conducted of three (3) staff. The following documents were also provided to LPA by email: House Rules; Memo-Subject: Reminder of Designated smoking areas and Consequences for violation Initial Training Records for staff; Non-Medical Medication: Polices, Procedures, Interaction of Drugs. MAR for Resident #1 (R1). (Please see LIC 9099C for additional information) SubstantiatedRead the full finding— CDSS inspection report, September 1, 2021 · control 28-AS-20210803093535

Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nune Margaryan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegations of "Staff did not administer medications as prescribed, There is a strong odor of marijuana present inside the facility and Facility has inadequate staffing for the residents while in care". Upon arriving at the facility, LPAs met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan conducted a prior visit to this facility on 7/7/21, in reference to the allegations listed above. During the course of the investigation, LPA interviewed the Assistant Administrator and Receptionist / Jeanette Velasquez. LPA was unable to interview Resident #1 (R1) and Staff members #1 and 2 (S1 and S2) as R1 no longer resides at this facility and S1 and S2 are no longer employed at this facility (whereabouts are unknown at this time). During the visit conducted on 7/7/21, LPA toured the faRead the full finding— CDSS inspection report, September 1, 2021 · control 28-AS-20210706094631

Licensing Program Analyst (LPA) Cynthia Chan conducted the initial investigation for the allegation on illegal eviction. LPA arrived unannounced and met with Gretel De Santiago, Administrator Assistant and explained the purpose of the visit. Michael Murphy, Human Resources Director assisted LPA with the visit. The investigation consisted of the following: LPA obtained a copy of the staff roster and resident roster. LPA requested copies of the documents from Resident #1’s (R1) file: 30-day eviction letter, Appraisal/Needs and Services Plan, House Rules, and Facility notes/Usual Incident Reports. LPA also interviewed Kandice Williams, the Executive Director, 3 Staff, and 2 Residents. (Continue on LIC9099C) SubstantiatedRead the full finding— CDSS inspection report, August 11, 2021 · control 28-AS-20210806121901

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Resident wandered away from the facility". During today's visit, LPA interviewed the Assistant Administrator and reviewed the file of Resident #1 (R1). LPA obtained copies of the following documents in reference to R1; • Physician's Report • Unusual Incident/Injury Report • Resident Information Sheet • Medical Reports The investigation revealed the following; Based on the interview conducted and file review, LPA discovered that on 7/27/21, at approximately 1PM, R1 left the facility through the side gate, located in the parking lot. Once facility staff discovered R1 went missing, SubstantiatedRead the full finding— CDSS inspection report, August 3, 2021 · control 28-AS-20210728115738

Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. LPA Spencer was met by assistant administrator Alex Solorio and explained the purpose of today's visit. The investigation consisted of the following: On 5/26/21, LPA Spencer conducted a health & safety check and obtained copies of the staff and resident roster. On 7/30/21, LPA Spencer interviewed the assistant administrator, staff #1-2 (S1-S2), and residents #1-3 (R1-R3). R4 was not at the facility and was unable to be reached by phone after several attempts. LPA Spencer collected copies R4's face sheet, physician's report, call light pendant acknowledgement form, hospital bed order form, and discharge papers. The investigation revealed the following: regarding allegation facility is not ensuring resident obtains necessary medical equipment, it was alleged the the facility did not ensure that a resident was provided with a hospital bed. ***Narrative contRead the full finding— CDSS inspection report, July 30, 2021 · control 28-AS-20210525125201

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Illegal eviction". Upon arriving at the facility, LPA met with HR Representative / Michael Murphy and was later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan conducted a prior visit to this facility on 5/21/21, in reference to the allegation listed above. On 6/2/21, LPA Linda M Almaraz conducted a complaint investigation at this facility regarding the same allegation (Illegal eviction), involving the same resident, Resident #1 (R1). During the course of the investigation, LPA Almaraz discovered that the facility had served R1 a 30 day eviction notice for refusing medication and verbally abusing staff. The 30 day eviction notice was served to R1 on 5/13/21. The eviction notice stated the resident had yelled at staff several times from 7/2020 though 5/2021 and had been calRead the full finding— CDSS inspection report, July 7, 2021 · control 28-AS-20210514091631