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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 06/29/2023
Date Signed: 06/29/2023 04:02:22 PM


Document Has Been Signed on 06/29/2023 04:02 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: 72DATE:
06/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Resident Care Director / Maria “Luisa” RazoTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan and Associate Governmental Program Analyst (AGPA) / Jeannette Rodriguez conducted an unannounced case management visit to this facility. During a complaint investigation conducted on 6/29/23, LPA and AGPA toured the facility and observed that the facility did not have a functional signal system in all resident rooms, for all residents. Per Title 22 Regulations Section 87303 / Maintenance and Operation;
(i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or
buildings shall have a signal system which shall:
(A) Operate from each resident's living unit.
(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory
signal at the living unit loud enough to summon staff.
(C) Identify the specific resident living unit.

During the tour, the LPA and AGPA also observed Room #16 to be unsanitary. The room was dirty, the floors had stains and were sticky and there was debris/trash on the floor of the living area and also the bathroom.


The following deficiencies were 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 Resident Care Director 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: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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 06/29/2023 04:02 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: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2023
Section Cited
CCR
87303(i)(1)

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Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
(A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit.
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Administrator will ensure that the facility has a functional signal system installed in each resident's living unit and submit proof of correction to CCL by the POC due date.
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This requirement is not being met as evidenced by:
During today's visit, LPA and AGPA toured the facility and observed that the facility did not have a functional signal system in all resident rooms, for all residents. This poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/01/2023
Section Cited
CCR87303(a)

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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.
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The Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, Section 87303. POC is due to CCL by the POC due date of 7/1/23.
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This requirement is not being met as evidenced by: During the tour, the LPA and AGPA also observed Room #16 to be unsanitary. The room was dirty, the floors had stains and were sticky and there was debris/trash on the floor of the living area and also the bathroom. This poses a potential health, safety or personal rights risk to persons in care.
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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: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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