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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602345
Report Date: 11/02/2021
Date Signed: 11/02/2021 01:47:04 PM

Document Has Been Signed on 11/02/2021 01:47 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VILLA GARDENSFACILITY NUMBER:
197602345
ADMINISTRATOR:JEFFREY SIANKOFACILITY TYPE:
741
ADDRESS:842 EAST VILLA STREETTELEPHONE:
(626) 796-8162
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 340CENSUS: 128DATE:
11/02/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Paula Digerness TIME COMPLETED:
02:00 PM
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Licensing Program Analyst(s)(LPA) Mary Flores and Jewel Baptiste conducted a case management continuation visit to review medication. LPAs met with Paula Digerness administrator and explained the reason for the visit.

LPAs reviewed medication for Resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9), #10(R10),#11(R11),#12(R12),#13(R13),#14(R14),#15(R15),#16(R16),#17(R17),#18(R18),#19(R19), #20(R20),#21(R21),#22(R22). 11 out 22 residents are independent and facility does not handle their medication. LPAs reviewed medication for the following residents: R9,R12,R13,R15,R16,R2,R3,R21,R17,R18, R19,R20 and are in compliance.

LPAs reviewed COVID 19 staff training and updates for 2020 and 2021. Facility is providing staff training at least once a month.

Exit interview was conducted with Paula Digerness administrator and a copy of this report was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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