197602345-10-22-2021-28-AS-MGFS-C82UQN-20211022154725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:47:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	VILLA GARDENS		FACILITY NUMBER:	197602345
ADMINISTRATOR:	JEFFREY SIANKO		FACILITY TYPE:	741
ADDRESS:	842 EAST VILLA STREET		TELEPHONE:	(626) 796-8162
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY:	340	CENSUS:	DATE:	10/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Paula Digerness		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, review of medication and food. LPA met with Paula Digerness administrator and explained the reason for the visit. Facility is licensed to serve as a Continuing Care Residential Community (RCFE-CCRC) for 340 non ambulatory adults 65 and over, of which 5 may be bedridden in rooms 150-169. Delay Egress is approved in1st and 2nd floor and a secured perimeter is approved in the 1st floor . Facility has an approved hospice waiver for 20 residents. Facility has a commercial kitchen, a swimming pool with a 5ft fence surrounding accessible with a key card pad, a gym, a dining room, library, different common areas in the 1st, 3rd, and 5th floor, and a dementia unit with delay egress system. Facility is currently serving 18 hospice residents. LPA conducted a tour of the facility with administrator Paula Digerness which consisted of the following: Kitchen - staff #1 observed wearing face mask under the nose. Refrigerators, freezer, and pantry were observed with sufficient food supplies LPA observed at least 2 days of perishables and 7 days of non-perishables, and temperature was observed at 40 degrees for refrigerators and 0 degrees for freezer. The following resident rooms were observed with all furniture, bedding, and light fixture as follow: Independent Living Room #444,519,437,302,542,205,314. Assisted living services rooms #252 - half bed rails observed, #215 - windex bottle cleaner observed on top of bathroom ,#405 ,#312 half bed rails observed,#524 knife and medication observed in kitchen area,#268, #529 knife in kitchen and PRN medication/cleaning supplies in unlock closet in hallway, #352 half bed rails and PRN medication observed in bathroom, #454 knife set in kitchen and half bed rails observed. Dementia unit rooms #159 half bed rails observed, #161 half bed rails observed, #168, #169 half bed rails observed. Each resident with half bed rails has a physician's request on file. Water temperature was tested in each room between 108.9 - 119.8 degrees F which is within the required water temperature of 105 - 120 degrees F. (CONTINUED LIC 809C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 197602345
	VISIT DATE: 10/22/2021

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Facility is following COVID 19 recommendations regarding: screening conducted for staff/residents/visitors, signs are posted throughout, cleaning and disinfecting done at least each shift in high touch areas, care staff has been Fit test for N95s, staff #1 was observed wearing mask under nose in the kitchen area, #2 observed not wearing a face mask while cleaning a resident's room, staff #3 was observed not wearing a face mask while providing care for a resident in room #312, and an out source contractor providing activities in the dementia unit was observed wearing a face mask under the nose. Technical Advisories were provided for infection control deficiencies.

Administrator Certificate #6027186740 expiration date 6/17/21 was observed along with forms submitted to the department for renewal of certificate.

LPA was unable to review medication during this visit due to time restrains and will return at a different time to finish annual review.

Deficiencies were given during this visit under Title 22 Division 6 Chapter 8 and noted on LIC 809D.

Exit interview conducted with administrator Paula Digerness and a copy of this report LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 197602345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

Storage Space Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 20 rooms observed were cleaning supplies were accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2021
	Plan of Correction
1 2 3 4	Administrator will ensure all residents' rooms in assisted living do not have access to cleaning solutions or poisons, unless determined by a physician that they may handle items a picture of area will be submitted to the deparment by 10/25/21.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC809 (FAS) - (06/04)

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