Senior Care Records.

Facility Evaluation Report

Villa Gardens, Pasadena05/09/2025Licence 197602345

Capacity340
Census233
Date signed05/09/2025 05:04:06 PM
Name of licensing program analystMary G Flores
Name of licensing program managerTony Vasallo
The inspector’s account

Licensing Program Analyst (LPA)s Mary Flores and Blanca Gonzalez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPAs met with Shaun Rushforth administrator and explained the reason for the visit.

Facility is licensed to serve as a Continuing Care Residential Community (RCFE-CCRC) for 340 non- ambulatory adults 60 and over, of which 5 may be bedridden in rooms 150-169. Delay Egress is approved in 1st and 2nd floors and a secured perimeter is approved in the 1st floor. Facility has an approved hospice waiver for 20 residents. Facility consist of a lobby, library, cafe, a dining room, commercial kitchen, wellness office, a swimming pool, a gym, a fitness room, craft room, lounge room, game room, activity room, other common areas in the 1st, 3rd, and 5th floor. It consist of 5 floors and a basement, 2nd - 5th floor houses residents in independent and assisted living, the first floor consist of common areas, some assisted living, and dementia unit with delay egress system. basement consist of activity areas.

LPAs toured the facility with Alex Alvarado and Aura Molina the following domains were reviewed during this visit:

Operational Requirements: Facility maintains a plan of operation, infection control plan, fire clearance. Facility is operating within the limitations of their license. They have 6 residents under hospice and 1 bedridden resident. A current liability insurance was observed.

Physical Plant/Environmental Safety: During facility's tour LPAs observed all common areas in good repair. A total of 24 random residents' rooms for independent, assisted, and dementia unit. Each room was furnished, with sufficient lighting, and bedding supplies. Water temperature was tested in each resident's bathroom and tested between 107.7 - 122.1 degrees F., which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars. (CONTINUED ON LIC 809C)

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction