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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602925
Report Date: 11/18/2025
Date Signed: 01/30/2026 09:55:18 AM

Substantiated


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
05/16/2025 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250516103008
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: 53DATE:
11/18/2025
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Kim Commodore-AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff is yelling at residents.
INVESTIGATION FINDINGS:
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***This licensing report supersedes the licensing report delivered on 11/18/2025. The purpose of the visit is to add additional information not included in the report dated 11/18/2025 and to reissue the citation. The findings will remain the same and the previous citation issued on 11/18/2025 will be dismissed. ***

On today’s visit, Licensing Program Analyst (LPA ) Sanjay Vaid spoke with Administrator Kim Commodore and discussed the purpose of the visit. Today census is ??

On 11/18/2025, Licensing Program Analyst (LPA) Sanjay Vaid conducted subsequential visit and met with Administrator Kim Commodore and discussed the above-mentioned allegations. LPA Vaid and Commodore toured the facility and did not observe any health and safety concerns.

On 5/21/25, Licensing Program Analyst (LPA) Sanjay Vaid conducted the initial complaint investigation at the facility and was met by Assistant Administrator Theresa Webb, and the reason for the visit was discussed. LPA Vaid and Webb toured the facility and did not observe any health and safety concerns.


CONTINUED ON 9099C...............
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
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 3
Control Number 28-AS-20250516103008
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: 11/18/2025
NARRATIVE
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The investigation consisted of; review of requested/obtained documents; staff roster, client roster, R1’s face sheet, R1 placement agency contact, R1’s physician report dated 09/09/2025, R1’s medical/health summary dated 08/19/2021, a court ordered examination/competency evaluation dated 03/02/2015, R1’s third party caregivers. Review of R1’s court order dated 04/09/2015. Interviews with staff, residents and witnesses and LPA observations.

NOTE: Due to the displacement of individuals from 2025 Eaton Fires, The facility, has been housing residents on an emergency basis, including R1.

Regarding the allegation: Staff is yelling at residents. It is alleged that staff are yelling at residents in care. Five (5) of five (5) staff interviewed stated they are not yelling at residents in care. Three (3) of five (5) staff admit to raising their tone of voice to redirect residents, but never to degrade residents. Staff interviewed stated that R1 was displaced due to the Eaton Fire and R1 was placed at the facility on a temporary basis, since, 01/08/25. Staff #4-#5 (S4, S5) are from R1’s prior facility, which is also owned by the licensee. S4 and S5 are employed at R1’s former facility and perform wellness checks on their displaced residents on a weekly basis. Per LPA’s interview with W2, W2 recalls sitting with R1 in facility dining hall when S5 approached R1 about toileting concerns that were occurring during the night. W2 stated witnessing S5 humiliate and ridicule R1 in front of other residents by approaching R1 and offering R1 adult briefs. S5 and R1 began to argue, R1 called S5 degrading names and S5 then yelled at R1. According to W2, several other residents were present and observed the argument. Four (4) of seven (7) residents interviewed stated a few staff have become indifferent since the Eaton Fires and have taken their frustration upon residents. Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the a found Above allegation is be substantiated.

Citation is being issued on a LIC 9099D, California Code of Regulations, Title 22, Division 6 & Chapter number 8, are being cited on the attached LIC 9099D.

Exit interview conducted with Administrator Kim Commodore and a copy of LIC 9099, LIC 9099C and LIC 9099D. Appeals rights discussed and a copy of appeal right were provided to Administrator Kim Commodore.

Note Cite Section 87468.1 Personal Rights
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250516103008
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.


This Requirement was not met by evidence of:
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Administrator to conduct Personal Rights in-service staff training.

Submited in-service training to LPA on 11/25/2025.
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Based on interviews, S5 approached R1 and W2 in the dining room and spoke to R1 about R1's nightly accidents causing R1 to feel ridiculed and humiliated in front of other residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3