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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 08/23/2024
Date Signed: 08/23/2024 04:03:54 PM


Document Has Been Signed on 08/23/2024 04:03 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: 77DATE:
08/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Alexander Solorio - Assistant AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi initiated a Case Management- Deficiencies after it was discovered during the course of the investigation for complaint control # 28-AS-20240818225123 that the facility's air conditioning in the dining room and the ice machine are broken. LPAs conducted a tour of the dining and kitchen areas and observed the room to be warm and has (1) fan going. And that there's no ice in the ice machine and is broken.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during today's visit is documented on 809D.

Exit interview held and a copy of the report along with appeal 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: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
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 2


Document Has Been Signed on 08/23/2024 04:03 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: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Administrator agreed to submit a service report/invoice from Air Conditioning/Heating company to prove that the A/C in the dining room has been fixed. And submit receipt/photos of new ice machine to CCL/LPA by POC due date.
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Based on observation and interviews, the Administrator did not comply with the section cited above in which LPAs observed the dining room's air conditioning is inoperable and the ice machine is broken which poses potential health, safety or personal rights risks 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: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2