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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 11/02/2021
Date Signed: 11/02/2021 01:48:49 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 GARDENSFACILITY NUMBER:
197602345
ADMINISTRATOR:JEFFREY SIANKOFACILITY TYPE:
741
ADDRESS:842 EAST VILLA STREETTELEPHONE:
(626) 796-8162
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY:340CENSUS: DATE:
11/02/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:TIME COMPLETED:
02:00 PM
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Licensing Program Analyst(s)(LPA) Mary Flores and Jewel Baptiste conducted a plan of correction visit for deficiencies given on 10/22/21.

On 10/22/21 LPA Flores gave deficiency on:
87309(a)(1) Storage Space -. LPA Flores observed PRN medication and cleaning supplies in room #215 and #529. On 11/2/21 LPAs observed updated physician's report for resident in room #215 and tour room #529 and observed a lock cabinet under the bathroom sink, Daisy Abarrientos Wellness Director moved additional cleaning items to the cabinet during the visit. Resident in room #529 has a private caregiver who provides PRN medication stored in resident's room which will be kept under lock. Deficiency cleared.

Exit interview was conducted with Paula Digerness administrator and a copy of this report, and clear letter was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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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