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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 02/01/2022
Date Signed: 02/01/2022 03:35:13 PM

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: 60DATE:
02/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
03:45 PM
NARRATIVE
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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 2/1/22, LPA discovered that the facility failed to update R1's Appraisal/Needs and Services Plan as required by Title 22 Regulations.

Based on interviews conducted and records reviewed, LPA discovered that R1's health began deteriorating around the end of December 2021 and beginning of January 2022. R1 was observed by staff and R2 (roommate) to be disoriented and paranoid. Due to a decline in health, R1 was often observed to be hallucinating. As a result, R1 was transferred to a private room on 1/6/22. After reviewing the Appraisal/Needs and Services Plan for R1 dated 10/12/21, LPA discovered that the changes in R1's physical, medical, mental, and social condition was not updated on the Appraisal/Needs and Services Plan. This poses a potential health and safety risk to R1.

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 to the Assistant Administrator along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 198603286
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/08/2022
Section Cited

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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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Based on interviews conducted and records reviewed, LPA discovered that R1's health began deteriorating around the end of December 2021 and beginning of January 2022. R1 was observed by staff and R2 (roommate) to be disoriented and paranoid. Due to a decline in health, R1 was often observed to be hallucinating. This poses a potential health and safety risk to 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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2022
LIC809 (FAS) - (06/04)
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