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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603286
Report Date: 10/18/2023
Date Signed: 10/18/2023 03:39:42 PM


Document Has Been Signed on 10/18/2023 03:39 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:
10/18/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee- Eyal Shtorch / Assistant Administrator Alexander Solorio TIME COMPLETED:
03:45 PM
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Present during this meeting were Licensing Program Manager (LPM) Fernando Fierros, David Sicairos, and Former Caseload Licensing Program Analyst (LPA) Ashley Calderon conducted an announced informal meeting at Monterey Park Adult and Senior Care Regional Office. Present from Pasadena Villa Senior Living was Licensee/ Eyal Shtorch and Assistant Administrator / Alexander Solorio.

The following items listed below were discussed during today's meeting:
  • High Volume of complaints reported to CCL since licensed.
  • Discussed appropriate placement for residents in care.
  • Number of in-house Residents from Department of Health (DHS): 30 residents
  • Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility
  • Licensee agrees to participate in the Technical Support Program (TSP) referral will be submitted by Licensing , TSP: CCL program assisting with free service in assisting facilities with facility issues/concerns.
  • Facility will conduct a Resident meetings to discuss with residents when it is appropriate to call 911.
  • Facility will submit plan by 10-31-23 to ensure staff are being trained to communicate with residents and working with residents to resolve issues in house.
  • Discuss Three (3) Day versus Thirty (30) day eviction procedures and Illegal Eviction
  • Discussed Substantiated complaints 2021/ 2022 / 2023.

Continuation 809-C...
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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 2


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: 10/18/2023
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  • Change of Administration -CCL waiting hard copy of Board of Resolution Letter, to be submitted to LPA Calderon by 10/27/23.
  • Topics covered: Personal Rights 87486, Personal Accommodations and Services 87307, 87618 Oxygen Administration, Reporting Requirements 87211, Maintenance and Operations 87303, Incidental Medical and Dental Care 87465, Postural Supports 87608, Night Supervision 87415, Eviction Procedures 87224, Basic Services 87464, Criminal Record Clearance 87355, Personnel Requirements- General 87411, Managed Incontinence 87625, Additional Person Rights of Residents in Privacy Operated Facilities 87468.2, and 87468.1 Personal Rights of Residents in All Facilities


An exit interview was conducted with Licensee/ Eyal Shtorch and Assistant Administrator / Alexander Solorio, a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Ashley CalderonTELEPHONE: (323) 981-3984
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2