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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 05/27/2023
Date Signed: 05/27/2023 12:47:26 PM

Document Has Been Signed on 05/27/2023 12:47 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
GREATER LA AC/SC, 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: 70DATE:
05/27/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Silvia Bernal - Med Tech TIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced case management continuation -annual visit at the facility using the CARE tool. . LPA Flores met with Silvia Bernal Med-Tech and explained the reason for the visit.

During this visit the following CARE tool domains were reviewed: Planned activities, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Facility has planned activities posted on hallway, a library with reading material, and an activities director.
On 4/22/23 - LPA Flores conducted a review of medication for 5 residents during initial annual visit. Resident #1(R1) did not have 4 medications listed. Resident #2(R2) was out of 1 medications listed on medication sheet. Resident #4(R4) was out of 3 prescribed medications and 1 medication was out of the original package. Per Med-Tech medications have not been provided for weeks, however the medication sheet is initial as provided. During facility's tour LPA observed resident's medication on top of bed frame in shared bedroom #4.
On 5/27/23 LPA reviewed emergency disaster plan. Last fire drill was conducted on 12/20/22 for the morning staff, 2/22/23 for the evening staff, and 2/23/23 for the night staff.
On 4/22/23 - During facility's tour LPA observed full bed rails for R3 and resident #5(R5) and half bed rails for R2, resident #4(R4) and resident #6(R6). R3,R4,and R5 did not have a physician's order request on file.
On 4/22/23 - LPA was made aware facility handles P&I money for residents. On 5/27/23 LPA reviewed P&I money for R2,R6, resident #7(R7),#8(R8),#9(R9) and record of resident's safeguarded cash resources for R2 and R8 balance was not written in log, for R2 as it is written R2 should have a balance of $70.00 and there is no money available. Facility did not provided a copy of surety bond.

Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Scarlett Munoz - Receptionist and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2023
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
Document Has Been Signed on 05/27/2023 12:47 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/27/2023 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in observation of medication for resident was observed on top of the bed frame in shared bedroom #4 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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Licensee will submit LIC 9098 certifying that medication will be maintain centrally store and schedule in-service training regarding the importance of ensuring medication is not left unattended for staff by POC due 5/29/23. In-service training with time duration, topic, and sign-in log is to be submitted by 6/6/23.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in medication for R4 was observed outside original labeled package which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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Licensee will certify in LIC 9098 that medication will be properly stored in original label prescribe package at all times and schedule in-service training by POC due date 5/29/23. In-service training will be provided on section 87465 and a copy of sign-in log, topic, and duration of training should be submitted by 6/6/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/27/2023 12:47 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/27/2023 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 resident's medication reviewed were missing 1 or more medications and medication sheet was initialed and provided to residents in care; R1,R2,R4 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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Licensee will certify on LIC 9098 that medication is order and provided as prescribed to residents by POC due date5/29/23. In-service training to be provided on section 87465 and a copy of sign-in log, topic, and duration of training is to be submitted by 6/6/23.
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 residents have full bed or half bed rails and a physician's request is not on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2023
Plan of Correction
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Administrator will obtain physician's request for R3,R4, and R5 and submit a copy to the department y POC due date 5/29/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/27/2023 12:47 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/27/2023 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in last fire drill conducted for each shift was conducted on 12/20/22, 2/22/23, and 2/23/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Adminsitrator will conduct an emergency drill at facility for each shift and submit a copy to the department by POC due date 6/2/23.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in emergency disaster plan LIC 610D reviewed did not have date of last update or review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator will review and update LIC 610D emergency disaster plan and submit a copy to the department by POC due date 6/2/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/27/2023 12:47 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/27/2023 at 12:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87217(g)(1)
Safeguard of Residents
(g) Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following: (1) Records of residents' cash resources maintained as a drawing account shall include a ledger accounting (columns for income, disbursements and balance) for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in review of P&I money showed R2 should have a balance of $70 per log and there was no money on envelope and R8's balance was not tracked on log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator willreview and properly log P&I money for R2 and R8 , will submit a copy of log and pictures of money to the department, and will provide trainig on section 87217 to Assistant administrator and business office director P&I by POC due date 6/2/23.
Type B
Section Cited
CCR
87216(a)
87216 Bonding
(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in during visit LPA was not provided a copy of surety bond which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Administrator will provide a copy of surety bond to the department by POC due date 6/2/23.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2023


LIC809 (FAS) - (06/04)
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