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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 07/10/2026
Date Signed: 07/10/2026 06:02:38 PM

Document Has Been Signed on 07/10/2026 06:02 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 GARDENSFACILITY NUMBER:
197602345
ADMINISTRATOR/
DIRECTOR:		SHAUN RUSHFORTHFACILITY TYPE:
741
ADDRESS:842 EAST VILLA STREETTELEPHONE:
(626) 796-8162
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 340CENSUS: 243DATE:
07/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Shaun Rushforth, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility using the CARE inspection tool. Upon arrival, LPA met with the Administrator Shaun Rushforth. The reason for the visit was explained.

The facility is licensed as a Continuing Care Residential Community (RCFE-CCRC) to serve 340 non- ambulatory adults who are 60 years old and over, of which five (5) may be bedridden in rooms 150-169. The facility building has five (5) floors with a total of 221 resident rooms and a basement. Delayed Egress is approved on the first and second floors. A secured perimeter is approved on the first floor. Facility has an approved hospice waiver for 20 residents. Facility consists of a lobby, library, Bisto (café), a dining room, commercial kitchen, wellness office, a swimming pool, gym, fitness room, craft room, lounge room, game room, TV/ activity room, and common areas. The basement has activity areas and employee lounge. From 2nd - 5th floor, it consists of 179 resident rooms (apartments) for independent and assisted living residents. The first floor consists of 42 residential living/ assisted living resident rooms, and dementia unit with delayed egress system.

The following CARE tool domains were reviewed during this visit:

Infection Control: Sufficient PPE supplies and an Infection Control Plan maintained at the facility were observed and in compliance.

(-Continued on the LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2026
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: 07/10/2026
NARRATIVE
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Physical Plant & Environment Safety: Physical plant tour was conducted. Residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The backyard, outdoor and passageways were free of obstruction and debris/hazards. Storage areas for cleaning solutions, toxins, knives, and hazardous items were kept in a locked cabinet and were inaccessible to residents. Water temperature was tested and the temperatures were between 109.8 to 112.1 degrees F., which is in compliance with regulations. Swimming pool was secured by gate card and surrounded with a 6 ft fence. Smoke detectors and carbon monoxide detectors were monitored by a fire prevention company and the last service was on 12/11/25. Fire extinguishers were observed and fully charged.

Operational Requirements and Disaster Preparedness: Facility has an activity area furnished for outdoor use. Fire drills were conducted quarterly. The last fire drill was on 06/18/26. Call system was tested. The staff’s responding time was from 2 minutes to 5 minutes, which was in compliance.

Staffing and Personnel Records- Training: There appears to be sufficient staffing at all times in the facility. Staff files were reviewed and in compliance. Administrator certificate is current with the expiration date on 09/17/2026.

Resident Rights-Information and resident Records-Incident Reports: Facility provided telephone landline and internet for the residents. Resident rights posters and reporting posters were displayed within the facility.

Food Service: The kitchen was observed to be clean. Two (2) days of perishables and one-week (7) days of non-perishables food supply were observed.

Health Related Service: Medication was properly labeled, centrally stored, and in their original containers.

(-continued on LIC 809- C)

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 197602345
VISIT DATE: 07/10/2026
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Incidental Medical & Dental and Emergency Intervention: Staff designated to administer medication have the proper training on file. Residents at this facility do not need the use of restraints or de-escalation techniques, however, staff maintain a CPI Certificate in the case of use.

Exit:

Deficiencies were noted during this visit per California Code of Regulations, Title 22, Division 6. Exit interview was conducted with Administrator Shaun. Copies of LIC 809s and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2026 06:02 PM - It Cannot Be Edited


Created By: Bonnie Tao On 07/10/2026 at 05:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 197602345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:

Per Resident#1 SF's medication record, Guaifernsein 600 mg should have 1 pill remained but there are 3 pills in the bottle. Per resident #2 ED's medicaiton record, AMlopipine should have 14 pills remined but there are 16 pills in the bottle. They showed descrepancies from the records.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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Licensee agrees to provide 1) in-service training to the med staff, 2) a statement indicates how to prevent further medication discrepancies, 3) check all residents' medication that come in loose bottles. Provide proof of correction on the due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Bonnie Tao
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2026


LIC809 (FAS) - (06/04)
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