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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 07/27/2022
Date Signed: 07/27/2022 03:30:33 PM

Document Has Been Signed on 07/27/2022 03:30 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: 58DATE:
07/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. During a complaint investigation conducted on 7/27/22, LPA discovered that the facility failed to report an Unusual Incident/Injury Report to Community Care Licensing (CCL) as required by Title 22 Regulations / Reporting Requirements.

On 7/17/22, at approximately 5:50pm, there was an incident involving R1. S1 was on shift and conducting a walk through of the facility and checking on residents when S1 noticed R1 was smoking marijuana and drinking beer in the designated smoking area (back end of the facility). S1 also noticed a bag containing additional marijuana on top of the table, where R1 was sitting. S1 confiscated the bag containing the marijuana and locked it in the front office and reported the incident to facility management. The Pasadena Police Department was involved and conducted a visit on 7/18/22.

During today's visit, LPA requested the Assistant Administrator to complete an Unusual Incident/Injury Report and submit a copy to CCL no later than the end of business day on 7/27/22.

The following deficiency was 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 along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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 07/27/2022 03:30 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 07/27/2022 at 02:49 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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2022
Section Cited
CCR
87211(a)

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Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Assistant Administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and submit a written plan detailing how he will ensure that incidents are reported to the CCL office as required according to the Regulation. Also, an Unusual Incident/Injury Report must be submitted to CCL no later than the end of business day
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This requirement is not met as evidenced by;
On 7/17/22, at approximately 5:50pm, there was an incident involving R1. S1 noticed R1 was smoking marijuana and drinking beer in the designated smoking area (back end of the facility). S1 also noticed a bag containing additional marijuana on top of the table, where R1 was sitting. S1 confiscated the bag containing the marijuana and locked it in the front office and reported the incident to facility management. The Pasadena Police Department was involved and conducted a visit on 7/18/22.
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on 7/27/22, in reference to the incident involving R1.

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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: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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