complaint·May 18, 2022

The investigation revealed the following; Allegation: Resident is smoking around an oxygen tank. The details of this allegation states that R1 lights up cigarettes and smokes inside her room. R1 uses an oxygen tank and should not be lighting up or smoking cigarettes inside her room. Based on interviews conducted, LPA learned that Residents 1 and 2 require the use of oxygen administration and are able to administer oxygen on their own. On multiple occasions, R1 was observed by multiple staff and residents lighting up cigarettes inside her room, while oxygen is in use. This poses an immediate health, safety or personal rights risk to persons in care as smoking is prohibited where oxygen is in use. The Assistant Administrator has become aware of this concern and has developed a Behavior Contract with R1 stating that R1 will follow the house rules of Pasadena Villa, R1 will smoke in the designated smoking area and request assistance from staff to be escorted to the smoking area. Failure to follow the Behavior Contract will result in loss of permanent housing and eviction for R1. R1 has agreed and signed the Behavior Contract dated 5/9/22. According to the Assistant Administrator, R1 has been following the Behavior Contract as of 5/9/22 and is no longer non-compliant. Based on interviews conducted and record review, there is sufficient evidence to support this allegation to be true. Allegation: Facility doesn't have enough towels for residents. Based on majority of the interviews conducted the statements obtained were consistent and corroborated with the allegation. At 11:35am, LPA toured the facility and inspected the linen closets and laundry room and observed a low supply of bath towels for 53 residents. From interviews conducted, LPA learned that some residents are left without bath towels while their dirty towels are in laundry and some residents have to use a bath robe or a blanket to dry themselves after a bath as the facility does not have an extra supply of bath towels. Based on interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true. Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided along with the Appeals Rights. Based on interviews conducted the statements obtained were inconsistent and did not corroborate with the allegation. Clients and Staff interviewed confirmed that there is no concern with laundry not being done. Laundry is done regularly, which is once a week or as needed. Based on the information gathered, there is insufficient evidence to support the allegation to be true. 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. An exit interview was conducted and a copy of this report was provided .