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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 04/05/2024
Date Signed: 04/05/2024 04:26:12 PM


Document Has Been Signed on 04/05/2024 04:26 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: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: 83DATE:
04/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Alexander Solorio - Assistant AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs met with Assistant Administrator, Alexander Solorio and the purpose of the visit was explained. There are currently eighty three (83) elderly residents 60 years and older residing in the facility. Facility is licensed to care for elderly residents age range 60 and over, 97 non-ambulatory, of which 30 may be bedridden. Hospice waiver for 30.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed.  There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Facility has Covid-19 signage posted throughout the facility including notification at the front door of exposure to Covid-19 if an individual visits the facility. Staff are adhering to infection control requirements.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Hospice Waiver for 30 is approved. A fire clearance is in place. Fire Drill was last conducted on 3/27/2024. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 04/01/2025. Surety bond in the amount of $10,000 is current.

Physical Plant/Environment Safety: The facility is a single story building which consist of reception area, large dining area, forty nine (49) resident bedrooms, administration office, medication room, kitchen, storage room, cooler, electrical room, conference room and outdoor seating/smoking areas. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. LPAs tested hot water temperature in eight (8) random rooms. Water temperature readings in Room #s 11, 33 and 34 did not measure within the required 105 - 120 degrees Fahrenheit.

Rm #4 - 111.5 deg F


Rm #11 - 124.5 deg F - 2nd reading 113.9 deg F
Rm #14 - 109.2 deg F
Rm #24 - 113.1 deg F
Rm #33 - 134.9 deg F - 2nd reading 132 deg F
Rm #34 - 131.3 deg F
Rm #38 - 114.6 deg F
Rm #45 - 113.5 deg F

*****CONTINUED ON LIC809-C****
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: PASADENA VILLA SENIOR LIVING
FACILITY NUMBER: 198603286
VISIT DATE: 04/05/2024
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Staffing: A total of twenty five (25) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: LPA reviewed eight (8) staff files and confirmed health screenings and fingerprint clearances. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator Kandice Vergara's certificate expired on 3/15/2024. Assistant Administrator submitted the renewal on 2/14/2022 and has not received his certificate.
Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. LPAs observed that the activities calendar posted near the dining room was not up-to-date. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities. Food Service:  Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be wearing hair nets and disposable gloves while working.
Incidental Medical and Dental: Nine (9) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided.
Resident Records/Incident Reports: Resident files are maintained at the facility. A total of eight (8) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted in the hallway near the dining area. The Incident report binder was reviewed.
Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. Records of resident Appraisal and Needs services plans are part of Emergency training.
Residents with Special Health Needs: Currently, eleven (11) residents receive hospice care and seven (7) bedridden residents. Half bed rails for mobility assistance were observed in some resident beds.  Functional Capability and Preplacement Appraisals are on file. "Oxygen In Use" signs were posted on the resident doors who are using oxygen.

Deficiencies issued on LIC809-D. An exit interview was conducted, and a copy of this report was provided to Alexander Solorio, Assistant Administrator along with the Appeals Rights.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/05/2024 04:26 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: PASADENA VILLA SENIOR LIVING
FACILITY NUMBER: 198603286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 water temperature readings in Room #s 11 (124.5 deg F), 33 (134.9 deg F) and 34 (131.3 deg F) did not measure within the required 105 - 120 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to residents in care.



LPAs observed that the faucet in Room #19 was broken, no water coming out on cold water side, and the bathroom sink in Room #18 was clogged which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2024
Plan of Correction
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Assistant Administrator will submit a 7-day log of water temperature of the 3 rooms mentioned to CCL/LPA by POC due date.
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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/05/2024 04:26 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: PASADENA VILLA SENIOR LIVING
FACILITY NUMBER: 198603286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

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 LPAs observed that the faucet in Room #19 was broken, no water coming out on cold water side, and the bathroom sink in Room #18 was clogged which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 04/12/2024
Plan of Correction
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Assistant Administrator will submit proof by sending photos and receipts of the fixed bathroom faucet and sink to CCL/LPA by POC due date.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above in that there is no current and valid Administrator certificate on file which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 04/12/2024
Plan of Correction
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Assistant Administrator will submit proof that Administrator courses had been completed and renewal for Administrator certificate has been submitted. Documents shall be sent to CCL/LPA by POC due date.
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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4