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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 05/26/2021
Date Signed: 05/27/2021 08:41:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PASADENA VILLA SENIOR LIVINGFACILITY NUMBER:
198603286
ADMINISTRATOR:MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY:97CENSUS: 35DATE:
05/26/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Assistant Administrator / Alexander Solorio
Business Office Director / Gretel De Santiago
Executive Director / Kandice Vergara		TIME COMPLETED:
03:00 PM
NARRATIVE
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An informal virtual conference was conducted today at the Monterey Park Adult and Senior Care Regional Office. The purpose of this informal meeting was to discuss the number of complaints received against the facility, since the time of licensure (3/18/2020). A total of 23 complaints have been received up to date.

Present during this meeting were; Regional Manager for the Monterey Park Office / Araceli Ramirez, Licensing Program Manager / Adeline Ho, Licensing Program Analyst / Joe Katrdzhyan, Assistant Administrator / Alexander Solorio, Business Office Director / Gretel De Santiago and Executive Director / Kandice Vergara.

The following items listed below were discussed during today's informal meeting;
  • Number of in-house Residents from Department of Health (DHS). 23 residents out of the 35 census are from DHS.
  • Changes the facility has made in reference to staffing, to include hiring of additional staff, consultant and dietician
  • Re-structuring of the model system and residents served
  • Facility reaching out to DHS for counseling
  • Pacific Pace Program
  • Transfer of DHS residents from sister facility
  • Admission of new residents from DHS


During the meeting, the Executive Director was asked to provide a current copy of the LIC 500 / Personnel Report along with a plan addressing the concerns on the number complaints reported against the facility.

An exit interview was conducted and a copy of this report was provided to the Executive Director.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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