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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602345
Report Date: 11/25/2025
Date Signed: 11/25/2025 01:28:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2025 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251106145136
FACILITY NAME:VILLA GARDENSFACILITY NUMBER:
197602345
ADMINISTRATOR:SHAUN RUSHFORTHFACILITY TYPE:
741
ADDRESS:842 EAST VILLA STREETTELEPHONE:
(626) 796-8162
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY:340CENSUS: 19DATE:
11/25/2025
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Shaun Rushforth, Administrator and Alex Alvarado, Director of Health Services. TIME COMPLETED:
01:29 PM
ALLEGATION(S):
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Staff caused injury to resident
INVESTIGATION FINDINGS:
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Licensing Program analyst (LPA) Alberto Lopez made a subsequent unannounced complaint visit to investigate the above allegation. LPA met with Administrator Shaun Rushforth and discussed the purpose of the visit.

On 11/07/2025 Licensing Program Analyst (LPA) Alberto Lopez made initial 10-day complaint visit. LPA met with Shaun Rushforth, Administrator and Executive Assistant Rebecca Perez, the purpose of the visit was discussed with Shaun Rushforth, Administrator
LPA interviewed S1, and R1. Copies of staff and resident rosters obtained. Phone numbers of 2 staff. R1 face sheet.
LPA toured of memory care area of facility and did not observe any health and safety risks. No deficiency observed during visit.
Due to insufficient information available at this time, the above allegation needs further investigation.
(Continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20251106145136
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/25/2025
NARRATIVE
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(continued from 9099)

The investigation consisted of interviews with eight (8) total staff (S1-S8), five (5) residents (R1 – R5), and taking a tour of the memory care section of facility. LPA obtained documentation of all staff training on abuse and mandated reporting of abuse dated 10/15/2025, 10/27/2025, 11/11/2025, 11/13/2025 11/14/2025

The investigation revealed regarding allegation: Staff caused injury to resident. It is alleged that a facility staff pinched a resident’s nose that caused a bruise. LPA interviewed eight (8) staff and all eight (8) staff stated they were aware of the incident. LPA interviewed five (5) residents and four (4) of five (5) residents could not corroborate the allegation. The resident stated someone pinched resident's nose but was not able to provide details due to cognitive issues. On October 26, 2025, at or around 10:40am S3 reported that S3 was assisting in providing care for resident with S2. S3 stated S3 witness S2 grabbing resident’s nose when the resident let out a scream. S2 stated S2 may have grabbed resident’s nose. S2 stated S2 only remembered getting resident's nose for a split second but not resident's lip. The facility investigated the incident and stated that S2 admitted to grabbing the resident’s nose. LPA reviewed and obtained photo of the injury to resident’s nose. S2 was placed off schedule on 10/27/2025 pending an investigation and was terminated on 11/10/2025. There is sufficient evidence to support this allegation.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20251106145136
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:
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Facility will provided in-service on personal rights/abuse and send proof to LPA as proof of correction
Facility provided in-service to all staff immediately after the incident and terminated staff after an investigation.
Citation cleared. ***NO FURTHER ACTION REQUIRED****
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S2 admitted that S2 grabbed resident's nose causing an injury to resident's nose while providing care to resident on 10/25/2025 at around 10:40am which posed/posses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3