Routine inspection·March 29, 2022

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. The facility is licensed to serve for a capacity of 97 Non-ambulatory residents (of which 30 may be bedridden) ages 60 and above. The facility has an approved Hospice Waiver on file for thirty (30) residents. Pasadena Villa Senior Living does not have an approved Dementia Care Plan in its plan of operation and does not accept/care for residents with dementia. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility consists of 49 bedrooms, 28 bathrooms, 4 shower rooms (2 Main and 2 Private), a main dining room, 1 common room, a library, a kitchen, a salon, a medication rooms and several offices. The facility has a covered patio in front of the facility, and 2 courtyards. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. No large bodies of water were observed. There are no security bars or weapons on the premises. The facility has central air and heating accommodations. LPA toured a random selection of resident rooms. Resident rooms were furnished appropriately. Each resident room has a shared bathroom. The bathrooms were observed to be operational w/grab bars. Each resident has a call light button which is given to them upon admission. The call light button was tested in various rooms and is operable. The hot water temperature was tested throughout the facility. The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies and perishable food was stored in covered containers at the appropriate temperatures. No pesticides or poisons were stored in the food areas. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to Residents. The fire extinguishers were observed to be fully charged and in compliance. The facility has smoke detectors and carbon monoxide detectors in each resident room and in the hallways of the facility. A shaded area with chairs is provided to the residents. Medications are centrally stored in the locked medication room. A random selection of medications were reviewed to ensure they are being administered as prescribed and prescription and non-prescription PRN medications have signed and dated written orders from the physician. The following deficiencies were observed during today's visit; Between the hours of 11am - 1pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. In room #43, it was measured at 102.8 degrees F. In room #12, it was measured at 123 degrees F. At 1:10pm, LPA discovered medication Trazadone HCL 50MG (Take 1 tablet by mouth once daily at bedtime) was missing from facility for Resident 1. Between the hours of 11am - 1pm, LPA toured the facility and observed missing skid mats in one of the main showers and also in the private shower. Between the hours of 11am - 1pm, LPA toured the facility and observed resident rooms #115, #24, #17 and #43 were unsanitary and in need of cleaning. Urine was observed in the shared bathroom of room #115 and stains, dirt, food particles and dust were observed in rooms #24, #17 and #43. At 11:15am, LPA observed the table located near the dining room patio area was in disrepair (broken pieces). At 11:30AM, LPA observed the plywood behind the fascia board located near the roof facing the side of the property (near the parking lot) was in disrepair. A large piece was broken and missing. At 11:25am, LPA observed broken furniture/appliance, wheelchair, wheelbarrow, pieces of wood and a plantoon boat located in the outdoor passageway, near the parking lot. The following deficiencies were observed to be in violation under California Code of Regulations Title 22. (refer to 809D). An exit interview was conducted and a copy of this report was provided along with the appeals rights.