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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 01/18/2024
Date Signed: 01/18/2024 02:58:03 PM


Document Has Been Signed on 01/18/2024 02:58 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: 226DATE:
01/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Marie Brooks - Wellness Director TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit at the facility regarding incident report and SOC 341 submitted to the department on 1/3/24. LPA met with Marie Brooks and explained the reason for the visit.

On 1/3/24 LPA Flores received Incident Report and SOC 341 from facility reporting the following: On 1/3/24 Resident #1(R1) reported that a facility staff (S1) that an individual had attempted to assault her. Upon Administrator and staff further questioning R1, R1 stated that a month or two months ago Staff #1(S1) had told R1 "was going to rape" R1. In addition had heard S1 tell another staff about two nights ago of S1 intentions of rape. This was heard in R1's apartment. Then R1 continue to state that 2 weeks ago S1 had come into the room and fiddle with R1's clothes, upon R1 elbowing S1 left the room.Facility submitted Report of Suspected Dependent Adult/Elder Abuse to the following agencies; Pasadena Police Department, Ombudsman, Community Care Licensing on 1/3/24. Officer Patarino conducted a visit to the facility on 1/3/24 regarding the allegation.
The facility proceeded as follow: On 1/3/24 facility communicated with R1's physician regarding above allegation for medical care. On 1/5/24, per physician's order submitted a request for a psychological evaluation, updated R1's service plan, and conducted an internal investigation. Review of staff entering R1's room was conducted from 12/3/23-1/4/24.
LPA reviewed R1's and S1's files and requested copies of the following documents for R1:Resident's service plan updated on 1/5/24, Facility Communication to Physician dated 1/3/24. Physician's request dated 1/3/24, Resident Appraisal dated 1/5/24, Physician's Report dated 1/10/23, Face Sheet. Copies of Application for Employment, Personal Action, Form, and Emergency Contact Information update were obtained for S1. Per physician's report R1 is ambulatory and capable of self care. Per administrator R1 is an independent resident with some assist. Police officer notified administrator that case will be forward to detective unit.
LPA was unable to interview R1 due to quarantine guidelines and S1 was not schedule on shift.

No Deficiencies are noted during this visit. Exit interview was conducted with Marie Brooks and a copy of report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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