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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 06/17/2022
Date Signed: 06/17/2022 03:24:34 PM


Document Has Been Signed on 06/17/2022 03:24 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
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:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Daisy Abarrientos - Wellness Director TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, medication and food supplies. LPA met with Daisy Abarrientos Wellness Director 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 65 and over, of which 5 may be bedridden in rooms 150-169. Delay Egress is approved in 1st and 2nd floor and a secured perimeter is approved in the 1st floor . Facility has an approved hospice waiver for 20 residents. Facility has a commercial kitchen, a swimming pool with a 5ft fence surrounding accessible with a key card pad, a gym, a dining room, library, different common areas in the 1st, 3rd, and 5th floor, and a dementia unit with delay egress system. Facility is currently serving hospice residents.

LPA conducted a tour of the facility with Daisy Abarrientos Wellness Director which consisted of the following:
Kitchen - Refrigerators, freezer, and pantry were observed with sufficient food supplies LPA observed at least 2 days of perishables and 7 days of non-perishables, and temperature was observed at 40 degrees for refrigerators and 20 degrees for freezer the required temperature is 0 degrees for freezer. The following assisted living resident rooms were observed with all furniture, bedding, and light fixture as follow: #159,155,168 rooms #222,232,215, 207 do not have a skid mat, #255,303,330,337,432,420,413,405,406,551,537,529,524,520, Water temperature was tested in each room between 106.8 - 120 degrees F which is within the required water temperature of 105 - 120 degrees F.
Facility was advise to maintain social distance during meals per PIN 21-49ASC, all other guidance are been followed by the facility.
Deficiency was noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Daisy Abarrientos Wellness Director and a copy of this report, LIC809D,and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
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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Document Has Been Signed on 06/17/2022 03:24 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 197602345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(21)
General Food Service Requirements
(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in freezer with meats was observed at 20 degrees F on thermometer by the fan and thermometer by the door outside the refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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Licensee will ensure freezer's temperature is maintain within the required 0 degrees F at all times, will maintain a temperature log for 7 days and submit log to the department by POC due date 6/24/22.
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.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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