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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 09/15/2025
Date Signed: 09/15/2025 02:38:48 PM

Document Has Been Signed on 09/15/2025 02:38 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/
DIRECTOR:		MURPHY, MICHAELFACILITY TYPE:
740
ADDRESS:1811 N. RAYMOND AVETELEPHONE:
(626) 791-6232
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 97CENSUS: 56DATE:
09/15/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Bryanna Luke - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 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-20250820145116). The purpose of this visit is to issue deficiencies that were observed by LPA that are not part of the complaint allegation. The reason for the Case Management - Deficiencies was explained to Administrator Bryanna Luke.

During the complaint visit on 09/15/2025, LPA discovered that Resident #1 (R1)'s several unwitnessed fall incidents including those that happened on 08/10/2025, 08/11/2025 and 08/28/2025, resulting in injuries and required emergency visit/hospitalization were not faxed to Community Care Licensing (CCL). Interviews with the Administrator and Staff #2 (S2) confirmed that the incident reports were not faxed to Community Care Licensing (CCL) due to a broken fax machine. Additionally, the Administrator and S2 acknowledged R1's frequent falls and the need for a higher level of care or 1:1 supervision, however, a re-appraisal to assess R1’s condition was not completed.

Deficiencies noted on LIC 809D. Exit interview, a copy of this report along with the appeals rights were provided to Bryanna Luke, Administrator.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/15/2025 02:38 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/15/2025 at 01:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2025
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports..(1) A written report... for the resident within seven days of the occurrence of any of the events specified...report shall include the resident's name, age, sex and date of admission; date and nature of event;....(D) Any incident which threatens the welfare, safety or health of any resident.....
This requirement is not met as evidenced by:
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Administrator agreed to comply with Title 22 Regs. Reporting requirements and will fax the incident reports for R1 on 08/10/2025, 08/11/2025 and 08/28/2025 to CCL/LPA today, 09/15/2025.
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Based on interviews, records review, the Administrator did not comply with the section cited above in which R1's unwitnessed fall incidents that happened on 08/10/2025, 08/11/2025 and 08/28/2025, resulting in injuries and hospitalization were not submitted and faxed to CCL which poses a potential health, safety or personal rights risk to residents in care.
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****DEFICIENCY CLEARED DURING THE VISIT.*****
Type B
09/29/2025
Section Cited
HSC87463(b)(1)

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87463 Reappraisals...(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition....
(1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to:..
This requirement is not met as evidenced by:
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Administrator will ensure to comply with Title 22 reg 87463 regulation requirement to conduct reappraisals when there has been a change in residents' mental, medical or social condition. Administrator to submit self-certification that she read, reviewed and understood the regulation and submit it to LPA/CCL by POC due date.
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Based on interviews, records review, the Administrator did not comply with the section cited above in which a re-appraisal to assess R1’s condition was not completed which poses a potential health, safety or personal rights 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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