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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 07/26/2024
Date Signed: 07/26/2024 01:50:39 PM


Document Has Been Signed on 07/26/2024 01:50 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: 74DATE:
07/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Alexander Solorio - Assistant AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control # 28-AS-20240520102446). The purpose of this visit is to issue deficiency that was observed by LPA that is not part of the complaint allegations.

During the visit on 5/21/2024, LPA conducted a tour of the facility, and tested the water temperature in the community shower rooms. LPA observed that there was no hot water in any of the stalls in the community shower rooms. Water readings measured by LPA were: 90.8 deg F in stall #1, 98.6 deg F in stall #2 and 89.2 deg F in stall #3, all stalls were in the large community shower room. Interview with S1 confirmed that there has been no hot water due to a plumbing issue in the community shower rooms and that the water pressure was very low or water only dripped in some stalls. S1 indicated that a plumber already came in April 2024 and provided them the estimate. Some residents interviewed stated that only cold water was available and there was no hot water in the shower rooms.

Deficiency is noted on LIC 809D. Exit interview, a copy of this report and Appeals Rights were provided to Alexander Solorio, Assistant Administrator.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
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 07/26/2024 01:50 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: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2024
Section Cited
CCR
87303(e)(2)

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87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents for personal care.... shall deliver hot water. Hot water temperature controls shall be maintained... to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
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Asst. Administrator shall ensure that the hot water temperature in the community shower rooms meets Title 22 regulation. Asst Administrator shall immediately repair water pump and submit service report/invoice to CCL/LPA by POC due date.
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Based on interviews and observation, the hot water temperature readings during the visit on 5/21/2024 were 90.8 deg F in stall #1, 98.6 deg F in stall #2 and 89.2 deg F in stall #3, all stalls were in the large community shower room which poses an immediate health and safety risk to residents in care.
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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: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
LIC809 (FAS) - (06/04)
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