Incident investigation·February 25, 2025

On 2/25/25 at 09:35 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced visit to the facility to conduct a Case Management visit. LPA was greeted by Resident Care Director, Mary Jane Reyes and Administrator Alexander Solorio (Pasadena Administrator). LPA stated the reason for their visit. The purpose for the visit was to follow up on a self-reported incident (02-20-25) which alleged that Resident #1 (R1) was hit by a staff member on 02/19/25. LPA requested census, staff, and resident rosters. LPA reviewed R1's file obtained from Pasadena Villa Senior Living (198603286). LPA conducted a physical tour of the facility and interviewed staff and residents. LPA interviewed R1 regarding the incident and R1 revealed that their blanket was missing, they went retrieved it and went back into their room. When they went back into their room, staff #1 (S1) followed them, pulled the blanket from R1, pulled their hair and hit R1 in the chest area. S1 and S2 were interviewed by management staff and S1 and S2 had inconsistent stories. S1 is currently on administrative leave and S2 was removed from the Memory Care unit where R1 is currently residing. LPA interviewed S3 and S4 and both staff reported that when they arrived on shift that morning, R1 had reported the incident to them. S4 reported the incident to their management staff. The management staff interviewed R1 on the day of the incident, reported the incident via SOC341 to Community Care Licensing Department, Ombudsman, APS Police Department and R1's representative. The management staff also interviewed another staff-S5 who reported seeing S1 hit another resident recently which was reported on another SOC341. Resident #2 (R2) was interviewed but they did not confirm or deny any incident occurring. Let it be noted, R2 is in the Memory Care unit. Furthermore, management staff provided a mandated reporter training on 02/21/25 for all staff to report all incidents. LPA obtained a copy of the training. Based on LPA's record review staff and resident interviews, a citation will be issued on a 809-D Exit interview conducted, a citation(s) was issued, appeal rights and copy of the report was signed and delivered to the Resident Care Director.