197602345-5-27-2025-28-AS-MGFS-DH3QAM-20250527120009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 05/27/2025
Date Signed: 05/27/2025 12:00:25 PM

Document Has Been Signed on 05/27/2025 12:00 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
MONTEREY PARK ASC, 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		CENSUS: 233	DATE:	05/27/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Shaun Rushforth - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:15 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) Mary Flores conducted an unannounced case management - annual continuation visit at the facility using the CARE inspection tool. LPA Flores met with Alex Alvarado Director of Health Services and explained the reason for the visit. LPA reviewed the following domains during this visit: Infection Control: Facility maintains a copy of infection control and was last reviewed on 6/13/24. Housekeeping staff were observed maintaining sanitizing procedures and Chef was observed doing proper hand washing. All staff have a TB clearance. Staffing: Administrator certificate was reviewed for Shaun Rushforth #6020615740 exp. date: 9/17/2024. Renewal documents were submitted to the department on 11/23/24. CPR/First aid training was observed for staff. One employee is on duty on the premises, administrator is on call,one employee is on call at the premises, additional staff are awake and on duty at night. Pendant call buttons were tested for 3 residents and they were respond within 5 minutes. Personnel Records/Staff Training: LPA reviewed 10 staff files. Files were available for review, except for chef's file. Chef is hired through Compass Community Living Hospitality Group (CCL) agency as a contractor for the facility. Files include; TB clearance, health screening, background clearance, personnel record, and training. Planned Activities: Facility has a Director of Life Enrichment to coordinate activities provided at the facility. LPAs observed various stations throughout the facility with puzzles, and reading areas. Memory Care Unit has a sensory area in addition to activities provided. (CONTINUED ON LIC 809C)

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 197602345
	VISIT DATE: 05/27/2025

NARRATIVE

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Residents with Special Health Needs: Facility is serving 1 bedridden resident and 11 residents on hospice. Two hospices plans were reviewed. Facility has a fenced swimming pool, Dementia unit residents do not have access to knives/sharps, chemicals or medications, unless the physician allows them to have access to any. A delay egress system was observed and tested in the dementia unit.

No deficiencies were not during this visit.

Exit interview was conducted with Shaun Rushforth and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

LIC809 (FAS) - (06/04)

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