<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 03/29/2022
Date Signed: 03/30/2022 09:31:46 AM


Document Has Been Signed on 03/30/2022 09:31 AM - 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: 46DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. The facility is licensed to serve for a capacity of 97 Non-ambulatory residents (of which 30 may be bedridden) ages 60 and above. The facility has an approved Hospice Waiver on file for thirty (30) residents.
Pasadena Villa Senior Living does not have an approved Dementia Care Plan in its plan of operation and does not accept/care for residents with dementia. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility consists of 49 bedrooms, 28 bathrooms, 4 shower rooms (2 Main and 2 Private), a main dining room, 1 common room, a library, a kitchen, a salon, a medication rooms and several offices. The facility has a covered patio in front of the facility, and 2 courtyards. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. No large bodies of water were observed. There are no security bars or weapons on the premises. The facility has central air and heating accommodations.

LPA toured a random selection of resident rooms. Resident rooms were furnished appropriately. Each resident room has a shared bathroom. The bathrooms were observed to be operational w/grab bars. Each resident has a call light button which is given to them upon admission. The call light button was tested in various rooms and is operable. The hot water temperature was tested throughout the facility.

The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies and perishable food was stored in covered containers at the appropriate temperatures. No pesticides or poisons
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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 5


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
VISIT DATE: 03/29/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
were stored in the food areas. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to Residents. The fire extinguishers were observed to be fully charged and in compliance. The facility has smoke detectors and carbon monoxide detectors in each resident room and in the hallways of the facility. A shaded area with chairs is provided to the residents.

Medications are centrally stored in the locked medication room. A random selection of medications were reviewed to ensure they are being administered as prescribed and prescription and non-prescription PRN medications have signed and dated written orders from the physician.

The following deficiencies were observed during today's visit;
  • Between the hours of 11am - 1pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. In room #43, it was measured at 102.8 degrees F. In room #12, it was measured at 123 degrees F.
  • At 1:10pm, LPA discovered medication Trazadone HCL 50MG (Take 1 tablet by mouth once daily at bedtime) was missing from facility for Resident 1.
  • Between the hours of 11am - 1pm, LPA toured the facility and observed missing skid mats in one of the main showers and also in the private shower.
  • Between the hours of 11am - 1pm, LPA toured the facility and observed resident rooms #115, #24, #17 and #43 were unsanitary and in need of cleaning. Urine was observed in the shared bathroom of room #115 and stains, dirt, food particles and dust were observed in rooms #24, #17 and #43.
  • At 11:15am, LPA observed the table located near the dining room patio area was in disrepair (broken pieces).
  • At 11:30AM, LPA observed the plywood behind the fascia board located near the roof facing the side of the property (near the parking lot) was in disrepair. A large piece was broken and missing.
  • At 11:25am, LPA observed broken furniture/appliance, wheelchair, wheelbarrow, pieces of wood and a plantoon boat located in the outdoor passageway, near the parking lot.


The following deficiencies were observed to be in violation under California Code of Regulations Title 22.
(refer to 809D).
An exit interview was conducted and a copy of this report was provided 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: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/30/2022 09:31 AM - 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
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: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2022
Section Cited

1
2
3
4
5
6
7
Maintenance and Operation. Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F
8
9
10
11
12
13
14
(49 degree C).
This requirement is not met as evidenced by; Between the hours of 11am - 1pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. In room #43, it was measured at 102.8 degrees F. In room #12, it was measured at 123 degrees F. This poses an immediate health, safety risk to persons in care.
8
9
10
11
12
13
14
Type A
03/30/2022
Section Cited

1
2
3
4
5
6
7
Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by; At 1:10pm, LPA discovered medication Trazadone HCL 50MG (Take 1 tablet by mouth once daily at bedtime) was missing from facility for Resident 1. This poses an immediate health, safety risk to persons in care.
Type B
04/01/2022
Section Cited

1
2
3
4
5
6
7
Maintenance and Operation. Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by; Between the hours of 11am - 1pm, LPA toured the facility and observed missing skid mats in one of the main showers and also in the private shower. This poses a potential health, safety risk to persons in care.
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: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/30/2022 09:31 AM - 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
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: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited

1
2
3
4
5
6
7
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by;
8
9
10
11
12
13
14
Between the hours of 11am - 1pm, LPA toured the facility and observed resident rooms #115, #24, #17 and #43 were unsanitary and in need of cleaning. Urine was observed in the shared bathroom of room #115 and stains, dirt, food particles and dust were observed in rooms #24, #17 and #43. This poses a potential health, safety risk to persons in care.
8
9
10
11
12
13
14
Type B
04/12/2022
Section Cited

1
2
3
4
5
6
7
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by; At 11:15am, LPA observed the table located
8
9
10
11
12
13
14
near the dining room patio area was in disrepair (broken pieces).
At 11:30AM, LPA observed the plywood behind the fascia board located near the roof facing the side of the property (near the parking lot) was in disrepair. A large piece was broken and missing. This poses a potential health, safety risk to persons in care.
8
9
10
11
12
13
14
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: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 03/30/2022 09:31 AM - 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
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: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2022
Section Cited

1
2
3
4
5
6
7
Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
At 11:25am, LPA observed broken furniture/appliance, wheelchair, wheelbarrow, pieces of wood and a plantoon boat located in the outdoor passageway, near the parking lot. This poses a potential health, safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5