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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 07/06/2022
Date Signed: 07/06/2022 03:30:10 PM


Document Has Been Signed on 07/06/2022 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: 55DATE:
07/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Staff / Maddison Aceves
Assistant Administrator / Alexander Solorio		TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Case Management / Technical Assistance visit to this facility. Present during the visit were Nurses, Sharon Evangelista and Casey Cortes from Pasadena Public Health (PPH). Upon arriving at the facility, LPA and PPH Nurses met with Staff / Maddison Aceves and were later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit. The purpose of today's visit was explained. There are currently NO active cases of COVID at Pasadena Villa Senior Living.
During today's visit, a tour of the physical plant (inside) was conducted. The following recommendations were made by the PPH Nurses;
  • Sign placed on front door regarding visitation must clarify testing requirements for visitors. (Antigen test must be conducted 24 hours prior to visitation or a PCR / Blood test must be conducted 48 hours prior to visitation)
  • Place signs on resident doors located in yellow zone asking residents to "Keep resident doors closed".
  • Place Droplet & Contact Precaution signs on resident doors located in yellow zone.
  • Dispose/disregard face shields which are NOT all plastic.
  • Place hand sanitizer in TV / Activity room.
  • Conduct in-service training with staff on the importance of following instructions listed on labels of cleaning solutions, when disinfecting for COVID.
  • Place sign in staff break room stating maximum capacity for staff should not exceed 2 staff members at one time.
  • Place hand sanitizer and also alcohol wipes in staff break room.
  • Remove outdated signs located in TV / Activity Room and also in staff break room.
  • Use paper bags when storing reusable goggles.
  • Provide separate trash bins (w/lid) inside resident rooms located in yellow zone.
No deficiencies were observed at the time of this visit.
An exit interview was conducted and a copy of this report was provided to the Assistant Administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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