197602925-1-30-2026-28-AS-FFIS-DQZQYT-20260205113537

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602925
Report Date: 11/18/2025
Date Signed: 01/30/2026 09:57:25 AM

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
05/16/2025 and conducted by Evaluator Sanjay Vaid

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250516103008

FACILITY NAME:	ARBOR VISTA		FACILITY NUMBER:	197602925
ADMINISTRATOR:	COMMODORE, KIM		FACILITY TYPE:	740
ADDRESS:	811 E WASHINGTON BLVD		TELEPHONE:	(626) 797-7296
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	69	CENSUS: 53	DATE:	11/18/2025
		UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Kim Commodore-Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff is sleeping in the same room as resident.

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. The findings will remain the same. ***
On today’s visit, Licensing Program Analyst (LPA) Sanjay Vaid spoke with Administrator Kim Commodore and discussed the purpose of the visit. Today's census is 50.

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 an initial visit and met with 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 LIC 9099C.....

Unsubstantiated

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)

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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 sleeping in the same room as a resident. It is alleged that a facility staff person is sleeping in the resident’s room. Five (5) out five (5) staff denied the allegation. Staff interviewed stated that no facility staff person is sleeping in a residents’ room. Staff interviewed stated the R1 is a placement from the Eaton Fire and is a temporary resident since 01/08/25. Three (3) of four (4) witnesses interviewed stated R1 has a court order that was issued in April 2015. The court order allows R1 to be placed in a behavioral facility with constant 1:1 staff supervision that is provided to R1 on 24-hour basis for seven (7) days a week. R1’s placement agency placed R1 in the facility on 01/08/25, as a result of being displaced due to the Eaton Fires and informed the facility administrator of the details of R1’s court order. According to W1, R1 needs continuous and constant 1:1 staff supervision, therefore, per the court order, R1 is assigned two third party caregivers (W2, W3). W2 provides care and supervision to R1 for 24 hours/ 6 days per week and W3 provides care and supervision to R1 for 24 hours/1 day per week. R1’s placement agency assigned W2, W3 a bed in R1’s room to monitor and provide support to R1’s due to R1s behaviors issues. Based on records reviewed, interviews conducted. 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 conducted with Administrator Kim Commodore and a copy of LIC 9099, LIC 9099C were provided to Administrator Kim Commodore.

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)

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