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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 06/13/2024
Date Signed: 06/13/2024 01:24:05 PM


Document Has Been Signed on 06/13/2024 01:24 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
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:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Aura Molina - Nurse Assistant LeadTIME COMPLETED:
01:37 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Aura Molina and Lavern Villarba Care Service Manager and explained the reason for the visit. Shaun Rushforth arrived 10 minutes later.

Facility is licensed to serve as a Continuing Care Residential Community (RCFE-CCRC) for 340 non- ambulatory adults 60 and over, of which 5 may be bedridden in rooms 150-169. Delay Egress is approved in 1st and 2nd floors 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 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 Molina and Lavern Villarba and observed the following:
Facility is in good repair indoor and outdoor. Passageways and emergency exits are cleared. Facility has a sprinkler emergency system throughout. Commercial kitchen is clean, in good repair, Refrigerators and pantry were observed with sufficient food for at least 2 days of perishables and 7 days of non-perishables. All common areas were observed in good repair. Fireplaces are covered. LPA observed 17 resident rooms each is furnished, with sufficient lighting, in good repair. Bathrooms were observed with grab bars, 6 assisted living out of the 17 bedrooms observed did not have skid mat/strips and tested the water temperature in each room between 109.0 - 118.9 degrees F., which is within the required temperature of 105-120 degrees F.Dementia unit is accessible with a code, each egress door was tested and are in working condition. Dementia unit has a secured outdoor area. 2 out of the 17 resident rooms observed were in dementia unit. In room #164 a bottle of cleaning solution was observed accessible to the resident. Facility has a pool/jacuzzi area which has a 5ft fence surrounding it and is accessible with a key card pad lock. Fire extinguishers were observed throughout the facility and last checked on 12/7/23. Evacuation chairs were observed on top of each stairway. Elevators were in working condition.
During this visit LPA completed the following CARE inspection tool domains: Physical Plant/Environmental Safety Planned Activities, and Food Service. (CONTINUED ON LIC 809C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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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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
VISIT DATE: 06/13/2024
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LPA will return at a different date to continue annual inspection due to time restrains.

Deficiencies were noted during this visit per Title 22 Regulations.

Exit interview was conducted with Shaun Rushforth and a copy of this report, LIC 809D, 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: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/13/2024 01:24 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
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: 06/13/2024

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 LPA observed cleaning solution accessible to resident in room #164 in the dementia unit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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Administrator will provide an in-service training with staff and will communicate with family regarding maintaining cleaning solutions inaccessible to residents at all times by POC due date 6/14/24.
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: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/13/2024 01:24 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
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: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 6 out of 17 resident showers were observed without a skid mat/strip, room #164, 161, 257,253,207,413 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Administrator will work with maintenance and will provide skid strips in the residents showers, will take pictures and submit to the department by POC due date 6/20/24.
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: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4