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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 06/18/2024
Date Signed: 06/18/2024 04:12:22 PM


Document Has Been Signed on 06/18/2024 04:12 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:
06/18/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Aura Molina - Nurse Assistant LeadTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced continuation annual visit at the facility using the CARE inspection tool. LPA met with Aura Molina and explained the reason for the visit.

On 6/13/24 LPA Flores conducted an initial annual visit.

During today's visit LPA completed the following CARE inspection tool domains Infection Control, Operational Requirements, Personnel Records/Staff Training, Resident Rights/Information, Incidental Medical and Dental, Resident Records/Incident Reports, Residents with Special Health Needs.

LPA reviewed Emergency Disaster Plan last reviewed on 6/13/24 and Infection Control Plan last reviewed on 6/14/24. Last fire drill was conducted on 5/7/24.
Staff have completed 20 hours of training. Hospice files are in place for those residents on hospice.
LPA reviewed medication and files for 10 residents and 10 staff. Staff #8 and #9 were missing a TB test and Staff #11 did not have a background clearance.

Interview 5 residents and 5 staff.

LPA obtained a copy of liability insurance. Administrator certificate was observed for Shaun Rushforth 7006201740 exp. date: 9/17/24.

Deficiencies are noted on LIC 809D per Title 22 Regulations.
This visit concludes the annual visit for the facility.

Exit interview was conducted with Lavern Villarba 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: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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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Document Has Been Signed on 06/18/2024 04:12 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 staff does not have a background clearance which poses an immediate health, safety or personal rights risk to persons in care. *Civil Penalties were assess today for the total amount of $500.00*
POC Due Date: 06/19/2024
Plan of Correction
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Administrator will remove staff from schedule and will have staff obtain a background clearance. Administrator will provide a copy of background clearance to the department by POC due date 6/19/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 04:12 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 10 staff did not have a TB clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Administrator will obtain a TB clearance for staff #8 and #9 and will submit a copy to the department by POC due date 7/2/24.

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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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