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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 06/10/2023
Date Signed: 06/10/2023 02:53:03 PM


Document Has Been Signed on 06/10/2023 02:53 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 GARDENSFACILITY NUMBER:
197602345
ADMINISTRATOR:SHAUN RUSHFORTHFACILITY TYPE:
741
ADDRESS:842 EAST VILLA STREETTELEPHONE:
(626) 796-8162
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY:340CENSUS: 236DATE:
06/10/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Aura MolinaTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced case management visit - annual continuation. LPA met with Aura Molina and explained the reason for the visit.

During today's visit LPA continue the annual visit started on 6/8/23 and will finish the following domains:

Personnel Records
Resident Records
Infection Control
Residents with Special Needs and Health Needs
Incidental Medical and Dental.
LPA reviewed files and conducted interviews with 5 residents and 5 staff.

Administrator Certificate was observed for Shaun Rushforth #6020615740 exp. date: 9/17/24.

No deficiencies were observed during this visit.

Exit interview was conducted with Shaun Rushforth administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2023
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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