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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191222713
Report Date: 02/06/2025
Date Signed: 02/06/2025 12:03:15 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
02/03/2025 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250203172136
FACILITY NAME:PASA ALTA WESTFACILITY NUMBER:
191222713
ADMINISTRATOR:DEWALT BROWNFACILITY TYPE:
740
ADDRESS:1773 N. FAIR OAKSTELEPHONE:
(626) 398-9110
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:6CENSUS: 8DATE:
02/06/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Staci Mitchell - AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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9
Staff actions are making residents feel uncomfortable.
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with Administrator Staci Mitchell and the purpose of the visit was discussed.

On todays visit LPA conducted the following: LPA toured the physical plant, LPA interviewed staff #1-#4 (S1-S4), Staff #5 no longer works in the facility and was unavailble for interview, LPA interviewed Residents #1-#6 (R1-R6), LPA collected a copy of the staff and resident roster as well as documents from R1's and S5's file related to the allegation. The investigation revealed the following:


Conitnued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
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 2
Control Number 28-AS-20250203172136
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: PASA ALTA WEST
FACILITY NUMBER: 191222713
VISIT DATE: 02/06/2025
NARRATIVE
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In regards to the allegation "Staff actions are making residents feel uncomfortable." it is alleged that S5 has inappropriate conversations around the residents making them feel uncomfortable. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff stated that on 1/27/25 , R1 brought up that they overheard S5 having a political conversation with another staff that made them feel uncomfortable. The conversation was in private between (2) staff away from the residents. This was the only instance a resident expressed any possible issue with staffs conversations and it was addressed with S5 the same day. Interview with residents did not show that they had ever been made to feel uncomfortable by staff. R1 stated they had no issues with any conversations between staff and has never felt uncomfortable at the home. Based on interviews, observations and file review, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2