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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 10/21/2022
Date Signed: 10/21/2022 02:20:55 PM


Document Has Been Signed on 10/21/2022 02:20 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: 57DATE:
10/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Assistant Administrator / Alexander SolorioTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. Upon arriving at the facility, the following concern was observed;

At 9:30am, LPA was greeted by Staff #1 (S1) inside the facility (by the front door) and S1 was observed not wearing a face covering/mask, while working inside the facility. Also, upon entering the facility and walking inside the office area, LPA observed the Assistant Administrator / Alexander Solorio and Staff #2 also not wearing a face covering/mask, while working inside the facility. During today's visit, LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care.

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: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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 10/21/2022 02:20 PM - 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: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2022
Section Cited

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Infection Control Requirements. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.
This requirement is not met as evidenced by:
At 9:30am, LPA was greeted by Staff #1 (S1) inside the facility (by the front door) and S1
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was observed not wearing a face covering/mask, while working inside the facility. Also, upon entering the facility and walking inside the office area, LPA observed the Assistant Administrator / Alexander Solorio and Staff #2 also not wearing a face covering/mask, while working inside the facility. During today's visit, LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care.
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attendees along with the topics covered during the in-service training to CCL, by the POC due date.

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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: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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