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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 10/06/2021
Date Signed: 10/06/2021 03:38:25 PM

Document Has Been Signed on 10/06/2021 03:38 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
CCLD Regional Office, 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: 44DATE:
10/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Assistant Administrator / Alexander Solorio
Executive Director / Kandice Vergara-Williams		TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Luis Mora conducted an unannounced case management visit to this facility. Upon arriving at the facility, LPAs met with Assistant Administrator / Alexander Solorio and were later joined by the Executive Director / Kandice Vergara-Williams who assisted with the visit. The purpose of today's visit is to review the file of Resident #1 and tour the physical plant to ensure residents are not smoking marijuana inside the facility.

At 12:15PM, LPA Katrdzhyan toured the physical plant (inside/outside) with the assistance of the Executive Director and did not observe residents smoking marijuana inside the facility. Also, there was no odor of marijuana present inside/outside of the facility premises.
After reviewing the file of R1, LPA Katrdzhyan observed that at the time of admission, facility staff did not conduct a proper assessment of R1 as the Care Assessment/Evaluation, Functional Assessment, Mental Status Questionnaire and the Resident Appraisal were incomplete. Most of the answers to the questions listed on the forms were left blank.
Also, the Unusual Incident/Injury Reports were reviewed for R1 and it was determined that R1's behaviors changed between period April of 2021 through September of 2021 and facility staff did not update the Appraisal/Needs and Services Plan for R1 addressing the current changes. R1 had multiple incidents of not following the facility Guest Policy by sneaking unknown male individuals from the street into her room. R1 was involved in theft of using a card belonging to another resident and making unauthorized purchases. R1 was also involved in multiple incidents of selling drugs to other residents inside the facility and getting into physical and verbal altercations with other residents and staff. R1 is in the process of being evicted from the facility for being non-compliant with facility house rules.
The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Executive Director along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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 10/06/2021 03:38 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 10/06/2021 at 02:12 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: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2021
Section Cited
CCR
87457(c)(1)

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Pre-Admission Appraisal - General. Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. The appraisal shall include, at a minimum, an
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The Executive Director will review Title 22 Regulations, Section 87457 on Pre-Admission Appraisal and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.
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evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors.
This requirement is not met as evidenced by: After reviewing the file of R1, it was observed that at the time of admission, facility staff did not conduct a proper assessment of R1 as the Care Assessment/Evaluation, Functional Assessment, Mental Status Questionnaire and the Resident Appraisal were incomplete. Most of the answers to the questions listed on the forms were left blank. This poses a potential health and safety risk to the residents in care.
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Type B
10/15/2021
Section Cited
CCR87463(a)

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Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.

This requirement is not met as evidenced by:
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The Executive Director shall update R1's Appraisal/Needs and Services Plan to indicate the changes in behaviors which led to the eviction. The Plan shall be submitted to CCL by the POC due date.
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The Unusual Incident/Injury Reports were reviewed for R1 and it was determined that R1's behaviors changed between period April of 2021 through September of 2021 and facility staff did not update the Appraisal/Needs and Services Plan for R1 addressing the current changes. This poses a potential health and safety risk to the 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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