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Inspection visit

Routine inspection

PASADENA VILLA SENIOR LIVINGLicense 1986032861 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit. LPA met with Administrator Bryanna Luk and discussed the purpose of the visit. The facility is licensed to care for elderly residents age range 60 and over, 97 non-ambulatory, of which 30 may be bedridden and a hospice waiver for 30 has been approved. On today's date, the LPA observed and reviewed the following seven (7) Compliance and Regulatory Enforcement (CARE) tool domains: Infection Control, Operational Requirements, Physical Plant/Environmental Safety, Resident Rights/Information, Planned Activities, Food Services, and Disaster Preparedness. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an updated Infection Control Plan. Staff are adhering to infection control requirements. Operational Requirements: A fire clearance is in place. Hospice Waiver for 30 is approved. Valid Liability Insurance is in place. Valid Surety bond is in place. Last Fire Drill was conducted on 01/27/2026. Physical Plant/Environment Safety: The facility is a single-story building which consist of reception area, large dining area, forty-nine (49) resident bedrooms, administration office, business office, medication room, kitchen, storage room, cooler, electrical room, conference room, janitor's room, salon and outdoor seating/smoking areas. The interior and exterior physical plant was inspected. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. LPA toured random resident rooms which were newly painted and observed each bedroom to contain the required furniture and linens. Bathrooms were observed to be clean. The signal system was tested in various locations and is operable. [Continue to LIC809-C] The fire extinguishers were observed to be fully charged and in compliance. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are no security bars or weapons on the premises. Five (5) fire extinguishers were fully charged and last inspected on 03/24/2025. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in eight (8) random rooms (#9, #13, #24, #27, #34, #40, #42, #46) and the community shower room and the readings vary between 91.2 deg F to 132.6 deg F which did not meet the required 105 - 120 deg F stated in Title 22 regulations. Resident Rights-Information: Resident personal rights are posted. Notice of visiting policy is posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Facility provides equipment and space to accommodate both outdoor and indoor activities. LPA observed a monthly activity calendar. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. $ 250.00 Civil Penalty is being issued during today's visit as a result of a repeat violation within a 12-month period ( 87303(e)(2) ). LIC421FC provided to the Administrator during today's visit. ***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection at a later date.*** Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the as provided to the Administrator, Bryanna Luke.

Citations

1 citation recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87303(e)(2)Type A

    Based on observation, the licensee did not comply with the section cited above in that water temperature readings in Room #s 9 (124.1 deg F), 13 (122.1 deg F), 34 (132.6 deg F), 40 (127.2 deg F), and 46 (129.5 deg F) did not measure within the required 105 - 120 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the February 12, 2026 inspection of PASADENA VILLA SENIOR LIVING?

This was a inspection inspection of PASADENA VILLA SENIOR LIVING on February 12, 2026. 1 citation were issued: 1 Type A (serious).

Were any citations issued to PASADENA VILLA SENIOR LIVING on February 12, 2026?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "Based on observation, the licensee did not comply with the section cited above in that water temperature readings in Roo..."

What type of inspection was this?

This was a inspection inspection. inspection inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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