Pasadena Grove Health Center: Abuse Reporting Failure - CA
The complaint inspection, conducted by federal surveyors at the facility on North Fair Oaks Avenue, documented a failure to report suspected abuse to the facility's administrator within five working days of an initial report. The deficiency, cited under F0607, affected a small number of residents.
Five working days is not a long window. It is the span of a single work week, the minimum time a facility has to ensure its own leadership knows what may have happened to someone in its care. At Pasadena Grove, that window closed without the required notification reaching the administrator.
The inspection was triggered by a complaint, not a routine survey. That distinction matters. Complaint inspections happen because someone, a resident, a family member, a staff member, called to say something was wrong. Inspectors then arrive to determine whether that concern had merit. In this case, they found it did.
The citation classified the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected. Those classifications sit at the lower end of the federal harm scale. They do not mean nothing happened. They mean inspectors could not confirm, at the time of the survey, that a resident had suffered measurable physical injury as a direct result of the reporting failure.
What the classification does not capture is what a delayed report to an administrator actually prevents. When leadership is not notified, investigations do not begin. When investigations do not begin, staff who may have caused harm continue working. Residents who may need protection do not receive it. The reporting requirement exists precisely because the gap between an incident and a leadership response is the gap during which further harm becomes possible.
The facility's own plan of correction, as described in the inspection record, calls for submitting a follow-up investigative report form, or a substantively similar form, to the administrator within five working days of any initial report going forward. The plan does not detail what happened in the specific case that prompted the complaint, how long the delay lasted, or what, if anything, was done in the interim.
Pasadena Grove Health Center is licensed to serve residents who depend on the facility not only for their daily physical care but for the institutional protections that are supposed to surround them when something goes wrong. Those protections begin with a phone call or a written report to the person in charge. They begin with someone at the top of the facility knowing what happened before a week has passed.
At Pasadena Grove in December 2025, that did not happen. The inspection record does not say why.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pasadena Grove Health Center from 2025-12-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 27, 2026 · Our methodology
PASADENA GROVE HEALTH CENTER in PASADENA, CA was cited for abuse-related violations during a health inspection on December 19, 2025.
The deficiency, cited under F0607, affected a small number of residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.