197602345-5-9-2025-28-AS-MGFS-DGJ24C-20250509170342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 05/09/2025
Date Signed: 05/09/2025 05:04:06 PM

Document Has Been Signed on 05/09/2025 05:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	VILLA GARDENS		FACILITY NUMBER:	197602345
ADMINISTRATOR/ DIRECTOR:	SHAUN RUSHFORTH		FACILITY TYPE:	741
ADDRESS:	842 EAST VILLA STREET		TELEPHONE:	(626) 796-8162
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY: 340	TOTAL ENROLLED CHILDREN: 0	CENSUS: 233	DATE:	05/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:04 AM
MET WITH:	Shaun Rushforth - Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:15 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 (LPA)s Mary Flores and Blanca Gonzalez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPAs met with Shaun Rushforth 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 60 and over, of which 5 may be bedridden in rooms 150-169. Delay Egress is approved in 1st and 2nd floors and a secured perimeter is approved in the 1st floor. Facility has an approved hospice waiver for 20 residents. Facility consist of a lobby, library, cafe, a dining room, commercial kitchen, wellness office, a swimming pool, a gym, a fitness room, craft room, lounge room, game room, activity room, other common areas in the 1st, 3rd, and 5th floor. It consist of 5 floors and a basement, 2nd - 5th floor houses residents in independent and assisted living, the first floor consist of common areas, some assisted living, and dementia unit with delay egress system. basement consist of activity areas. LPAs toured the facility with Alex Alvarado and Aura Molina the following domains were reviewed during this visit: Operational Requirements: Facility maintains a plan of operation, infection control plan, fire clearance. Facility is operating within the limitations of their license. They have 6 residents under hospice and 1 bedridden resident. A current liability insurance was observed. Physical Plant/Environmental Safety: During facility's tour LPAs observed all common areas in good repair. A total of 24 random residents' rooms for independent, assisted, and dementia unit. Each room was furnished, with sufficient lighting, and bedding supplies. Water temperature was tested in each resident's bathroom and tested between 107.7 - 122.1 degrees F., which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars. (CONTINUED ON LIC 809C)

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 05/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 197602345
	VISIT DATE: 05/09/2025

NARRATIVE

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The following rooms were missing skid mats/strips in the showers #553,536,542,424,403,408,240, 210, 160,167. Facility's pool has a fence surrounding. Medication is stored in medication rooms. Passageways, hallways, stairways are clear of debris and obstructions. Auditory signal/pendant buttons were tested for 3 residents and staff responded within 5 minutes. Facility has a fire sprinkler system throughout. Fire extinguishers were observed and last checked on 12/6/24. Delay egress exit doors were tested and in working condition. Elevators were observed working.
Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted in the mailing room area.
Food Services: LPAs toured the commercial kitchen and observed good quality/commercial food supplies for at least 2 days of perishables and 7 days of non-perishables. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. A list for residents with modified diets was observed.
Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication carts in each medication room. LPAs reviewed medication for 10 residents. A log for PRN/Narcotics medication was observed.
Resident Records/Incident Reports: LPAs reviewed 10 residents files, each contained admission agreement, medical assessment, TB clearance, a current needs and care appraisal, pre-appraisal. Six residents were interviewed.
Disaster Preparedness: LPAs reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 6/13/24. Evacuation chairs were observed in each staircase. Emergency drills are conducted quarterly, last emergency drill was conducted on 3/25/25.

Deficiencies were noted per Title 22 Regulations.

LPA will return at a later time to continue annual visit and finish remaining domains. Exit interview was conducted with Shaun Rushforth and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/09/2025 05:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 197602345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). 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 24 rooms, room #207 tested at 122.1 degrees F., and #105 tetsed at 121.4 degrees F., which is not within the 105-120 degrees F.,which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2025
	Plan of Correction
1 2 3 4	Administrator will adjust water temperature and will certify water temperature will be under the required 105-120 degrees F., and submit to the department by POC due date 5/10/25.

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.

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 05/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/09/2025 05:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 197602345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(e)(5)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. 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 9 out of 24 residents' showers did not have a skid mat in rooms 553,536,542,424,403,408,240, 210, 160,167. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/16/2025
	Plan of Correction
1 2 3 4	Administrator will provide skid mats to the residents' showers and will provide a picture to the department by POC due date 5/16/25.

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.

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 05/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025

LIC809 (FAS) - (06/04)

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