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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 01/30/2024
Date Signed: 01/31/2024 07:54:13 AM


Document Has Been Signed on 01/31/2024 07:54 AM - 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: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: 76DATE:
01/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Alexander Solorio - Assistant Administrator TIME COMPLETED:
03:25 PM
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Licensing Program Analysts (LPAs) Mary Flores and Sanjay Vaid conducted an unannounced plan of correction (POC) visit at the facility regarding deficiencies noted on 1/16/24 during a complaint investigation visit. LPAs met with Alexander Solorio and explained the reason for the visit.

On 1/16/24 LPA Flores conducted a complaint investigation visit and noted the following deficiency:
87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities: During complaint investigation it was revealed that on 7/2/22 Resident #1(R1) who per physician's report cannot leave the facility unassisted, left the facility with another resident, did not returned to the facility and was found in a hospital the next day. On 1/30/24 Alexander Solorio provided a copy of in-service training provided to the staff on 1/16/24 and 1/17/24 and written statement acknowledging residents will obtain care and supervision. Deficiency cleared as of 1/30/24.

Exit interview was conducted with Alexander Solorio 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: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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