<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602925
Report Date: 06/16/2025
Date Signed: 06/16/2025 01:22:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/11/2025 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250611092527
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: 54DATE:
06/16/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kim Commodore-AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff spoke inappropriately to resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Kim Commodore, Administrator and explained the purpose of the visit.
The investigation consisted of the following: LPA reviewed and obtained copies of the staff & resident rosters, Staff #1 (S1) and Staff #2 (S2) in service training logs (Clients rights) and Write up/Consultation (dated 06/12/2025), Incident report (dated 04/14/2025), Pasadena Police information (Officer #5472) and Resident #1 (R1) - Resident #2 (R2) pertinent files. LPA also interviewed Staff #1 (S1) - Staff #4 (S4) and Resident #1 (R1) - Resident #6 (R6).
In regards to the allegation "Staff spoke inappropriately to resident", it is alleged that approximately 2 months ago, R1 heard a loud noise from R2's room and found R2 on the floor under a walker. R1 helped and called for help. S1 entered and aggressively told R1 to move, while S2 also scolded R1. S1 continued to berate and embarrassed R1 for interfering in front of other residents in the dining area. It is also alleged that on 06/08/2025, when R1 asked S1 for more food, S1 responded, "You’re gonna get fat!" ******CONTINUED ON LIC9099-C*****
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
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-20250611092527
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ARBOR VISTA
FACILITY NUMBER: 197602925
VISIT DATE: 06/16/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews conducted with (4) out of (4) staff members all denied the allegation. Staff members interviewed stated that they are naturally loud speakers, but they did not intend any disrespect to residents. Some staff also indicated that because some residents have hearing issues, they need to speak louder for them to hear. S4 denied the allegation regarding the incident on 06/08/2025 and stated that they did not body shame or make inappropriate comments to any residents. (5) out of (6) residents interviewed denied the allegation and indicated that staff treat them with respect and have not spoken improperly to them. LPA did not observe staff being disrespectful to residents, being loud or speaking in loud voices. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation.

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.



Exit interview held, and a copy of this report was provided to Kim Commodore, Administrator.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2