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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 06/08/2023
Date Signed: 06/08/2023 01:57:07 PM


Document Has Been Signed on 06/08/2023 01:57 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:
06/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Aura TIME COMPLETED:
02:15 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with and explained the reason for the visit. Administrator arrived 30 minutes later.

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.

LPA Flores conducted a tour of the facility with Aura and observed the following:
Facility is clean and in good repair indoor and outdoor. Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. LPA observed 17 independent/assisted living resident bedrooms were observed; each room has sufficient lighting, required furniture and bedding supplies. LPA observed cleaning solution in room #245's bathroom by the toilet. Each bathroom has the required skid mats and grab bars for the assisted living residents. Water temperature was tested in each residents' bathroom, and it tested between 109.8 and 118.9 degrees F., which is within the required 105-120 degrees F. Common areas have sufficient sitting area and are in good repair. Facility's gym is in good repair. Dementia unit has an activity area, and 2 resident rooms were observed. Facility has a fire sprinkler system throughout. Emergency disaster plan was reviewed. Last fire drill was conducted on 5/2/23.

LPA reviewed medication for 10 residents. LPA will return at a later time to finish the following domains: Personnel Records, Resident Records, Infection Control, Residents with Special Needs and Health Needs.
Deficiencies were noted on LIC 809D. Per Title 22 Regulations. Exit interview was conducted with Shaun Rushforth Administrator and a copy of this report, LIC809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
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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Document Has Been Signed on 06/08/2023 01:57 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
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: 06/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 that in room #245 a bottle of cleaning solution was observed next to the toilet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Administrator will remove the cleaning solution from room #245 and will certify an LIC 9098 by POC due date 6/9/23. Administrator will ensure that residents who are not independent per physician's report do not have any cleaning supplies accessible by 6/23/29.
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2023
LIC809 (FAS) - (06/04)
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