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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602925
Report Date: 03/24/2025
Date Signed: 03/24/2025 02:54:23 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
03/19/2025 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250319104152
FACILITY NAME:ARBOR VISTAFACILITY NUMBER:
197602925
ADMINISTRATOR:COMMODORE, KIMFACILITY TYPE:
740
ADDRESS:811 E WASHINGTON BLVDTELEPHONE:
(626) 797-7296
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:69CENSUS: 61DATE:
03/24/2025
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Kim Commodore-AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff abandoned resident at hospital.
INVESTIGATION FINDINGS:
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LPA Vaid conducted an Initial 10-Day complaint investigation regarding the above allegation. LPA was met by Thersa Webb, Assistant Administrator. Administrator Kim Commodore joined shortly after. LPA discussed the purpose of the visit. LPA toured the facility with Administrator and did not observe any health and safety concerns.

Investigation consisted of the following: interview of Staff #1 - Staff #5 (S1-S5); interviews of clients from client#1 through client #6 (C1-C6); requested, obtained, and reviewed client #1(C1) clients face sheet and ID, physicians report, client notes, house rules and admissions agreement. Staff roster and client roster.

Regarding the allegation: Staff abandoned resident at hospital. It is alleged that the facility staff had abandoned client at the hospital after client was sent to hospital for medical and psych evaluations after being involved in incidents at the facility on 03/16/25 and 03/17/25. Continued on 9099C......
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
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-20250319104152
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ARBOR VISTA
FACILITY NUMBER: 197602925
VISIT DATE: 03/24/2025
NARRATIVE
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Witness 1 interviewed stated that their family member has substance problem, are trying to seek help through rehabilitation however the client is reluctant to go to the rehab program after claiming they need help. Witness 2 stated, that the facility did allow client to return after discharge from hospital on 03/17 and 03/18. Five (5) out of six (6) clients interviewed could not corroborate this allegation. Clients interviewed stated they saw the police and paramedics in the facility however do not know why they were there. One client stated they saw the client in their room on the 03/17 and 03/18 being unruly. Five (5) out of five (5) staff interviewed denied this allegation. According to Administrator Kim Commodore the client has had previous issues with violating house rules and admissions agreement. On 03/16, client was found with drugs and drug parahelia and was sent to the hospital by police and paramedics after being becoming aggressive and confrontational, client was released from the hospital and was allowed back to the facility. On 03/17/25, client was again aggressive and combative with staff and other facility clients. Clients were complaining of the unruly noise and breaking of furniture, staff call PET team to take client on 51/50 hold. PET team and staff found client unresponsive in their room and called 911. Police and paramedics came to the facility and announced client had drug overdose. Client was transported to the Hospital and police reports were made on 03/16 -PA 2025-20784 and 03/17-PA 2025-20814 respectively, family was notified of each incident. Kim Commodore stated, after speaking with clients’ family on 03/18/25 about the house rules and agreements violated and this being the clients first incident, the client would be able return to the facility. On Administrator Kim provided the client and their family with rehab facility options. On 03/21/25 Administrator Kim last spoke to client, he was going to phone company to get new phone, client was accompanied by staff to the phone company. On 03/22/25, while client was allegedly supposed to be in rehab. Staff discovered client had been at Arbor Vista facility destroying the room and ran away, staff called police and family was notified. Currently, client is at the hospital having been found overdosed by family member on 03/23/25 who are trying to admit client to the rehab facility. Based on interviews conducted and documents reviewed. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Copy of this report was provided to Administrator Kim Commodore.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2