Pasadena Grove Health Center
PASADENA GROVE HEALTH CENTER in PASADENA, CA — inspection on December 19, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Administrator within 5 working days of the initial report.
The Facility will submit a follow-up investigative report form or a substantively similar form.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Pasadena Grove Health Center
1470 N Fair Oaks Ave Pasadena, CA 91103
SUMMARY STATEMENT OF DEFICIENCIES
During a concurrent interview and record review on 12/19/2025, at 3:02 PM, with Social Services Director (SSD), Resident 1's Progress Note dated 12/18/2025, was reviewed. SSD stated the Progress Note indicated Resident 1 was assaulted by another resident (Resident 2) (date of assault not indicated) and Resident 1 had called the police and CDPH on 12/18/2025. SSD stated she was not informed that on 12/18/2025, Resident 1 reported getting assaulted by Resident 2 to RNS 1. SSD stated she was not informed that Resident 1 called the police and the police came and talked to Resident 1 on 12/18/2025SSD stated Resident 1's abuse allegation should have been reported to the State Agencies immediately or within two hours after the allegation was reported. SSD stated it was important to report abuse to the State Agencies to have documentation of what took place and to ensure the safety of the residents involved.
During an interview on 12/19/2025, at 3:24 PM, with RNS 1, RNS 1 stated on 12/18/2025, Resident 1 was agitated and upset about her HTN medication. RNS 1 stated that while she was trying to calm Resident 1 down, Resident 1 informed her that she was being harassed in the facility and was assaulted by Resident 2 (unable to provide date of incident). RNS 1 stated the reported incident between Resident 1 and 2 should have been reported to the three State Agencies immediately or within two hours after Resident 1 reported it to her. RNS 1 stated it was important to report the incident to the three state agencies to protect and ensure the safety of the residents and to prevent further abuse. RNS 1 stated she did not follow the facility's abuse policy.
During an interview on 12/19/2025, at 4:06 PM, with the Director of Nursing (DON), the DON stated he saw the police arrive at the facility on 12/18/2025.
The DON stated he was informed by RNS 1 that Resident 1 was the one who called and spoke to the police.
The DON stated he did not know the reason for the police visit and did not ask Resident 1 or RNS 1 for the reason for the police visit.
The DON stated RNS 1 did not inform him on 12/18/2025 that Resident 1 reported to RNS 1 the Resident 1 was getting harassed and was assaulted by Resident 2.
The DON stated if there is any report of suspected abuse, it should be reported to the State Agencies within two hours.
The DON stated it was important to report suspected abuse to the abuse coordinator, CDPH, Ombudsman, and police so an investigation can be started, prevent future abuse in the facility, and for the safety of the residents.
During a review of the facility's policy and procedure (P&P), titled, Abuse Prevention and Prohibition Program, revised 8/2023, the P&P indicated the following:To ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for prevention, identification, investigation, and reporting of abuse.The Facility will report allegations of abuse immediately but no later than 2 hours after forming the suspicion- if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman.
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