Inspection Reports for
Pasadena Highlands

No deficiencies were noted during the visit. Reviews of staff and resident files, medication administration, infection control, and emergency preparedness plans were conducted and found compliant.

The complaint alleged that staff did not provide resident#1's authorized representative with resident records requested on 08/18/2025. Interviews with three staff members revealed the delay was due to verifying the legitimacy of the request. Records were sent by 09/18/2025. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation found that although staff initially delayed providing the requested records to ensure the legitimacy of the request, the records were ultimately sent and received by the authorized representative. There was insufficient evidence to prove the alleged violation occurred, and the allegation was unsubstantiated.

The complaint alleged that staff did not provide resident#1's authorized representative with resident records requested on 08/18/2025. Interviews with three staff members indicated the request was received but required verification of legitimacy before release. Records were sent by 09/18/2025. The allegation was unsubstantiated.

The investigation found that although there was a delay in providing the requested resident records, the facility did not deny the request and ultimately provided the records. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The allegation was that staff did not safeguard resident R-1's personal belongings, specifically a missing wedding ring. Interviews and documentation did not corroborate the allegation. The allegation was determined to be unsubstantiated.

The investigation included interviews with residents and staff, review of documentation, and a police report. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The allegation was that staff did not safeguard resident R-1's personal belongings, specifically a missing wedding ring. Interviews and documentation did not corroborate the allegation. The allegation was determined to be unsubstantiated.

The investigation included interviews with staff and residents, review of documentation, and a police report. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated for all allegations including inadequate supervision, unsafe transfers, pressure injuries, worsening condition, and isolation of the resident. The report explicitly states that there was not a preponderance of evidence to prove the alleged violations occurred.

The investigation found no preponderance of evidence to substantiate any of the allegations. Interviews with residents and staff, review of medical and hospital documentation, and facility records indicated that incidents were either assist to ground events rather than falls, staff responded appropriately, and no pressure injuries or neglect were confirmed.

The complaint investigation was unsubstantiated for all allegations including inadequate supervision, unsafe transfers, pressure injuries, worsening condition, and isolation. Documentation and interviews did not support the claims, and the facility responded appropriately to incidents.

The investigation found no preponderance of evidence to substantiate any of the allegations. Interviews with residents and staff, as well as review of medical and hospital documentation, indicated that incidents were either assist to ground rather than falls, injuries were minor and promptly addressed, and residents did not have pressure injuries or worsening conditions due to neglect. The allegation of isolation was also unsubstantiated.

The complaint involved allegations that staff did not adequately address changes in resident R1's condition related to dementia and failed to inform R1's POA of incidents. Interviews with staff, residents, and review of records did not substantiate these allegations. The report notes that although the allegations may have happened or be valid, there was insufficient evidence to prove violations occurred.

The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the claims, and documentation showed appropriate communication and care. The findings remain unsubstantiated.

The complaint involved allegations that staff failed to adequately address changes in resident R1's condition and failed to inform R1's power of attorney (POA) of incidents. Interviews with staff and residents, as well as review of records, did not substantiate these allegations. The report notes that although the allegations may have happened or be valid, there was insufficient evidence to prove violations occurred.

The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the claims, and documentation showed appropriate tracking and communication of residents' health conditions. The findings remain unsubstantiated.

The Licensing Program Analyst conducted interviews with residents and met with facility staff to explain the reason for the visit. An exit interview was conducted with the administrator and a copy of the report was provided.

Interviews were conducted with 7 residents regarding the incident that occurred at their previous facility. An exit interview was conducted with the administrator and a copy of the report was provided.

The complaint involved two allegations: 1) staff did not adequately address a change in resident R1's condition related to dementia, and 2) staff failed to inform R1's representative of incidents. Staff and residents denied these allegations. R1's POA confirmed some behavioral episodes but staff assisted by redirecting R1. The allegations were unsubstantiated due to lack of preponderance of evidence.

The investigation found no health or safety concerns during the facility tour. Interviews with staff and residents did not substantiate the allegations. Staff documented residents' health changes and communicated with responsible parties. Although some incidents occurred, there was insufficient evidence to prove violations, resulting in unsubstantiated allegations.

The complaint involved two allegations: 1) staff did not adequately address a change in resident R1's condition related to dementia, and 2) staff did not inform R1's POA of incidents. Both allegations were unsubstantiated after interviews with staff, residents, and the resident's POA, and review of records.

The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the allegations, and documentation showed appropriate tracking and communication of residents' health conditions. The resident's POA was involved during behavioral episodes, and staff assisted the resident accordingly.

The facility was found to be in compliance with all applicable regulations, with no deficiencies observed. The inspection covered infection control, physical plant safety, staffing, personnel records, resident records, residents' rights, planned activities, food service, incidental medical and dental care, disaster preparedness, and residents with special health needs.

The facility was found to be in compliance with all applicable regulations, with no deficiencies observed. The inspection covered infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, residents' rights, planned activities, food service, incidental medical and dental care, disaster preparedness, and residents with special health needs.

The complaint was unsubstantiated after investigation. Allegations included improper wound care handling, neglect causing wound worsening, failure to note medical changes, failure to seek timely medical attention, failure to provide wound care plan to family, and retaining a resident needing higher level of care. Interviews, document reviews, and hospice records were examined. The facility provided care and timely hospital transfers were made per family requests.

The investigation found that although the resident's wound worsened and care was provided by hospice and facility staff, there was insufficient evidence to substantiate the allegations of neglect or improper care. The facility documented changes in condition and timely hospital transfers upon family request. The family did not request copies of wound care plans from the facility. Overall, the allegations were unsubstantiated.

The complaint involved multiple allegations including improper wound care handling, neglect leading to wound worsening, failure to note medical condition changes, failure to seek timely medical attention, failure to provide wound care plan to family, and retaining a resident needing higher level care. The investigation included interviews with staff, residents, family, hospice care, and review of medical and facility records. The complaint was found to be unsubstantiated.

The investigation found that although there were allegations of neglect and improper wound care resulting in worsening wounds, the resident was receiving hospice services and skilled care. Facility staff documented changes in condition and timely hospital transfers were made upon family request. There was insufficient evidence to substantiate any violations, and all allegations were determined to be unsubstantiated.

The facility was found to be in full compliance with health and safety standards, including fire clearance and emergency preparedness. The memory care unit was ready and appropriately equipped to house residents with dementia needs.

The facility was found to be in full compliance with health and safety standards, including fire clearance and emergency systems. The memory care unit was ready and appropriately equipped to house residents with dementia needs.

The complaint was unsubstantiated based on interviews with 8 residents and 3 staff members, inspection of the facility, and review of pest control service records. A previous similar complaint was also unsubstantiated.

The investigation found no evidence of pests in the facility. Interviews with staff and residents, inspection of the facility, and review of pest control documentation revealed no observations of roaches, rodents, or flies. The allegation was determined to be unsubstantiated.

The complaint alleged that staff do not keep the facility free from pests. The allegation was unsubstantiated based on interviews, inspections, and documentation review.

The investigation found no evidence of pests in the facility. Interviews with staff and residents, inspection of the facility, and review of pest control documentation revealed no observations of roaches, rodents, or flies. The allegation was determined to be unsubstantiated.

The complaint investigation addressed four allegations: staff not keeping the facility free from pests, improper sanitization of kitchen items, failure to keep the facility free from mildew, and improper food handling techniques. All allegations were found to be unsubstantiated based on staff and resident interviews, observations, and documentation review.

The investigation found no preponderance of evidence to substantiate any of the allegations. Staff and residents denied the claims, observations and documentation supported proper pest control, sanitation, mildew cleaning, and food handling practices. Therefore, all allegations were determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff not keeping the facility free from pests, improper sanitization of kitchen items, presence of mildew, and improper food handling techniques. Interviews with staff and residents, observations, and document reviews did not confirm these allegations.

The investigation found no preponderance of evidence to substantiate any of the allegations. Staff and residents denied the claims, observations and documentation supported proper pest control, sanitation, mildew cleaning, and food handling practices. The allegations were therefore determined to be unsubstantiated.

The complaint investigation was triggered by allegations that staff did not keep the facility free from rodents, did not properly sanitize kitchen items, did not keep the facility free from mildew, and did not follow proper food handling techniques. After interviews with staff and residents, observations, and review of pest control and maintenance records, all allegations were found to be unsubstantiated.

The investigation found no preponderance of evidence to substantiate any of the allegations. Staff and residents denied the claims, observations and documentation supported proper pest control, sanitation, mildew cleaning, and food handling procedures. The allegations were all determined to be unsubstantiated.

The complaint included allegations that staff did not keep the facility free from rodents, did not properly sanitize kitchen items, did not keep the facility free from mildew, and did not follow proper food handling techniques. All allegations were investigated and found to be unsubstantiated based on staff and resident interviews, observations, and documentation review.

The investigation found no preponderance of evidence to substantiate any of the allegations. Staff and residents denied the claims, observations and documentation supported proper pest control, sanitation, mildew cleaning, and food handling practices. The allegations were therefore unsubstantiated.

The complaint alleged wrongful eviction of residents R1 and R2. The allegation was unsubstantiated after interviews with staff, residents, and review of documentation showed no eviction notices or wrongful eviction actions.

The investigation found no evidence of wrongful eviction. Staff and residents denied the allegation, and no eviction notices were found in the residents' files. The residents were moving out by choice, supported by a 30-day notice from the responsible party. The allegation was unsubstantiated due to lack of preponderance of evidence.

The allegation of wrongful eviction was investigated and found unsubstantiated based on interviews, observations, and document review.

The investigation found no evidence of wrongful eviction; staff and residents denied the allegation, no eviction notices were found, and it was confirmed that R1 and R2 are moving out by choice. The allegation was determined to be unsubstantiated.

The facility was found to be in compliance with all applicable regulations, with no deficiencies observed. The inspection covered infection control, operational requirements, physical plant safety, staffing, personnel records, resident records, residents' rights, planned activities, food service, incidental medical and dental care, and disaster preparedness.

The facility was found to be in compliance with all applicable regulations, including infection control, operational requirements, physical plant safety, staffing, personnel training, resident records, residents' rights, planned activities, food service, incidental medical and dental care, and disaster preparedness. No deficiencies were observed during the visit.

The allegation was that staff was not providing adequate care and supervision to a resident, specifically that the resident was denied care and the private caregiver was not allowed to administer medication. The allegation was unsubstantiated based on interviews and documentation reviewed.

The investigation found insufficient evidence to substantiate the allegation. Interviews with staff and residents, as well as file reviews, indicated that the resident received proper care and medication management was appropriately handled by certified staff.

The complaint alleged that staff was not providing adequate care and supervision to a resident, specifically that the resident was denied care and the private caregiver was not allowed to administer medication. The allegation was found to be unsubstantiated based on interviews and document reviews.

The investigation found insufficient evidence to substantiate the allegation. Interviews with staff and residents, as well as review of relevant documents, indicated that the resident received proper care and medication management was appropriately handled by certified staff.

The complaint alleged inadequate supervision of a resident who went missing on 01/21/2023. The investigation included interviews with staff and residents, review of resident files, and facility policies. The allegation was unsubstantiated due to lack of evidence.

The investigation found insufficient evidence to substantiate the allegation. Staff and residents interviewed denied the claim, and records showed adequate supervision and staffing. The resident in question was reported missing briefly but was not found after a search and police notification. The allegation was determined to be unsubstantiated.

The complaint alleged inadequate supervision of a resident who went missing on 01/21/2023. The investigation included interviews with staff and residents, review of resident files, and facility policies. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The investigation found insufficient evidence to substantiate the allegation. Staff and residents interviewed denied the allegation, and records showed adequate supervision and staffing. The resident in question was missing briefly but was not found to have been unsupervised in violation of care standards.

The facility was found to be in compliance with infection control and safety standards, including proper PPE usage, adequate supplies, and safe medication storage. No deficiencies were cited during this visit.

The facility was closed for new admissions and conducting twice-weekly COVID-19 testing. Communal areas were temporarily closed due to the outbreak, and residents isolated in their rooms. Infection control measures including hand sanitizers, PPE use, and cleaning protocols were observed. Residents and staff were generally compliant with mask-wearing and social distancing guidelines.

The facility was closed for new admissions and conducting twice-weekly COVID-19 testing. Communal areas were closed due to the outbreak, and residents isolated in their rooms. Infection control measures including hand sanitizers, PPE availability, cleaning protocols, and mask usage were observed and enforced throughout the facility.

The facility was found to be in compliance with infection control and safety standards, including adequate PPE supplies, proper signage, mask usage, and safe medication storage. No deficiencies were cited during the visit.

The complaint alleged that facility staff did not provide resident's records to the authorized representative upon written request. The allegation was unsubstantiated due to lack of evidence and proper authorization in the initial request.

The investigation found that the initial document request lacked proper authorization or power of attorney, making it a HIPAA violation to provide the documents. An updated request with proper authorization was provided on 08/31/2022, and the facility agreed to provide the requested documents accordingly. Therefore, the allegation was unsubstantiated.

The complaint was unsubstantiated. The allegation was that facility staff did not provide resident's records to the authorized representative upon written request. Staff interviews and record reviews showed the initial request lacked authorization. An updated authorized request was provided and the facility agreed to comply.

The investigation found that the initial document request lacked proper authorization or power of attorney, which would have been a HIPAA violation to provide documents without. An updated request with proper authorization was later provided, and the facility agreed to provide the requested documents accordingly. Therefore, the allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, and/or were without reasonable basis.

The investigation found that the alleged resident (R1) was not and has never been a resident of the facility. Interviews with multiple facility directors and observations of resident rooms showed no evidence supporting the allegations. The complaint was determined to be unfounded and dismissed.

The complaint alleged staff failures related to resident care plans, incontinence aid, and room odor. The complaint was investigated and found to be unfounded, meaning the allegations were false or without reasonable basis.

The investigation found that the alleged resident (R1) was not and has never been a resident of the facility. Interviews with multiple facility directors and observations of resident rooms and staff cleaning found no evidence supporting the allegations. The complaint was determined to be unfounded and dismissed.