Villa Gardens

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility using the CARE inspection tool. Upon arrival, LPA met with the Administrator Shaun Rushforth. The reason for the visit was explained. The facility is licensed as a Continuing Care Residential Community (RCFE-CCRC) to serve 340 non- ambulatory adults who are 60 years old and over, of which five (5) may be bedridden in rooms 150-169. The facility building has five (5) floors with a total of 221 resident rooms and a basement. Delayed Egress is approved on the first and second floors. A secured perimeter is approved on the first floor. Facility has an approved hospice waiver for 20 residents. Facility consists of a lobby, library, Bisto (café), a dining room, commercial kitchen, wellness office, a swimming pool, gym, fitness room, craft room, lounge room, game room, TV/ activity room, and common areas. The basement has activity areas and employee lounge. From 2nd - 5th floor, it consists of 179 resident rooms (apartments) for independent and assisted living residents. The first floor consists of 42 residential living/ assisted living resident rooms, and dementia unit with delayed egress system. The following CARE tool domains were reviewed during this visit: Infection Control: Sufficient PPE supplies and an Infection Control Plan maintained at the facility were observed and in compliance. (-Continued on the LIC809-C) Physical Plant & Environment Safety: Physical plant tour was conducted. Residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The backyard, outdoor and passageways were free of obstruction and debris/hazards. Storage areas for cleaning solutions, toxins, knives, and hazardous items were kept in a locked cabinet and were inaccessible to residents. Water temperature was tested and the temperatures were between 109.8 to 112.1 degrees F., which is in compliance with regulations. Swimming pool was secured by gate card and surrounded with a 6 ft fence. Smoke detectors and carbon monoxide detectors were monitored by a fire prevention company and the last service was on 12/11/25. Fire extinguishers were observed and fully charged. Operational Requirements and Disaster Preparedness: Facility has an activity area furnished for outdoor use. Fire drills were conducted quarterly. The last fire drill was on 06/18/26. Call system was tested. The staff’s responding time was from 2 minutes to 5 minutes, which was in compliance. Staffing and Personnel Records- Training: There appears to be sufficient staffing at all times in the facility. Staff files were reviewed and in compliance. Administrator certificate is current with the expiration date on 09/17/2026. Resident Rights-Information and resident Records-Incident Reports: Facility provided telephone landline and internet for the residents. Resident rights posters and reporting posters were displayed within the facility. Food Service: The kitchen was observed to be clean. Two (2) days of perishables and one-week (7) days of non-perishables food supply were observed. Health Related Service: Medication was properly labeled, centrally stored, and in their original containers. (-continued on LIC 809- C) Incidental Medical & Dental and Emergency Intervention: Staff designated to administer medication have the proper training on file. Residents at this facility do not need the use of restraints or de-escalation techniques, however, staff maintain a CPI Certificate in the case of use. Exit: Deficiencies were noted during this visit per California Code of Regulations, Title 22, Division 6. Exit interview was conducted with Administrator Shaun. Copies of LIC 809s and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 10, 2026

Allegation investigated: Staff caused injury to resident

Licensing Program analyst (LPA) Alberto Lopez made a subsequent unannounced complaint visit to investigate the above allegation. LPA met with Administrator Shaun Rushforth and discussed the purpose of the visit. On 11/07/2025 Licensing Program Analyst (LPA) Alberto Lopez made initial 10-day complaint visit. LPA met with Shaun Rushforth, Administrator and Executive Assistant Rebecca Perez, the purpose of the visit was discussed with Shaun Rushforth, Administrator LPA interviewed S1, and R1. Copies of staff and resident rosters obtained. Phone numbers of 2 staff. R1 face sheet. LPA toured of memory care area of facility and did not observe any health and safety risks. No deficiency observed during visit. Due to insufficient information available at this time, the above allegation needs further investigation. (Continued on 9099C) Substantiated (continued from 9099) The investigation consisted of interviews with eight (8) total staff (S1-S8), five (5) residents (R1 – R5), and taking a tour of the memory care section of facility. LPA obtained documentation of all staff training on abuse and mandated reporting of abuse dated 10/15/2025, 10/27/2025, 11/11/2025, 11/13/2025 11/14/2025 The investigation revealed regarding allegation: Staff caused injury to resident. It is alleged that a facility staff pinched a resident’s nose that caused a bruise. LPA interviewed eight (8) staff and all eight (8) staff stated they were aware of the incident. LPA interviewed five (5) residents and four (4) of five (5) residents could not corroborate the allegation. The resident stated someone pinched resident's nose but was not able to provide details due to cognitive issues. On October 26, 2025, at or around 10:40am S3 reported that S3 was assisting in providing care for resident with S2. S3 stated S3 witness S2 grabbing resident’s nose when the resident let out a scream. S2 stated S2 may have grabbed resident’s nose. S2 stated S2 only remembered getting resident's nose for a split second but not resident's lip. The facility investigated the incident and stated that S2 admitted to grabbing the resident’s nose. LPA reviewed and obtained photo of the injury to resident’s nose. S2 was placed off schedule on 10/27/2025 pending an investigation and was terminated on 11/10/2025. There is sufficient evidence to support this allegation. Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 28-AS-20251106145136

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Nov 26, 2025

87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: S2 admitted that S2 grabbed resident's nose causing an injury to resident's nose while providing care to resident on 10/25/2025 at around 10:40am which posed/posses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Facility will provided in-service on personal rights/abuse and send proof to LPA as proof of correction Facility provided in-service to all staff immediately after the incident and terminated staff after an investigation. Citation cleared. ***NO FURTHER ACTION REQUIRED****

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst(LPA) Mary Flores conducted an unannounced case management - annual continuation visit at the facility using the CARE inspection tool. LPA Flores met with Alex Alvarado Director of Health Services and explained the reason for the visit. LPA reviewed the following domains during this visit: Infection Control: Facility maintains a copy of infection control and was last reviewed on 6/13/24. Housekeeping staff were observed maintaining sanitizing procedures and Chef was observed doing proper hand washing. All staff have a TB clearance. Staffing: Administrator certificate was reviewed for Shaun Rushforth #6020615740 exp. date: 9/17/2024. Renewal documents were submitted to the department on 11/23/24. CPR/First aid training was observed for staff. One employee is on duty on the premises, administrator is on call,one employee is on call at the premises, additional staff are awake and on duty at night. Pendant call buttons were tested for 3 residents and they were respond within 5 minutes. Personnel Records/Staff Training: LPA reviewed 10 staff files. Files were available for review, except for chef's file. Chef is hired through Compass Community Living Hospitality Group (CCL) agency as a contractor for the facility. Files include; TB clearance, health screening, background clearance, personnel record, and training. Planned Activities: Facility has a Director of Life Enrichment to coordinate activities provided at the facility. LPAs observed various stations throughout the facility with puzzles, and reading areas. Memory Care Unit has a sensory area in addition to activities provided. (CONTINUED ON LIC 809C) Residents with Special Health Needs: Facility is serving 1 bedridden resident and 11 residents on hospice. Two hospices plans were reviewed. Facility has a fenced swimming pool, Dementia unit residents do not have access to knives/sharps, chemicals or medications, unless the physician allows them to have access to any. A delay egress system was observed and tested in the dementia unit. No deficiencies were not during this visit. Exit interview was conducted with Shaun Rushforth and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 27, 2025

Type of visit: Required - 1 Year

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) The following rooms were missing skid mats/strips in the showers #553,536,542,424,403,408,240, 210, 160,167. Facility's pool has a fence surrounding. Medication is stored in medication rooms. Passageways, hallways, stairways are clear of debris and obstructions. Auditory signal/pendant buttons were tested for 3 residents and staff responded within 5 minutes. Facility has a fire sprinkler system throughout. Fire extinguishers were observed and last checked on 12/6/24. Delay egress exit doors were tested and in working condition. Elevators were observed working. Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted in the mailing room area. Food Services: LPAs toured the commercial kitchen and observed good quality/commercial food supplies for at least 2 days of perishables and 7 days of non-perishables. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. A list for residents with modified diets was observed. Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication carts in each medication room. LPAs reviewed medication for 10 residents. A log for PRN/Narcotics medication was observed. Resident Records/Incident Reports: LPAs reviewed 10 residents files, each contained admission agreement, medical assessment, TB clearance, a current needs and care appraisal, pre-appraisal. Six residents were interviewed. Disaster Preparedness: LPAs reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 6/13/24. Evacuation chairs were observed in each staircase. Emergency drills are conducted quarterly, last emergency drill was conducted on 3/25/25. Deficiencies were noted per Title 22 Regulations. LPA will return at a later time to continue annual visit and finish remaining domains. Exit interview was conducted with Shaun Rushforth and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 9, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced continuation annual visit at the facility using the CARE inspection tool. LPA met with Aura Molina and explained the reason for the visit. On 6/13/24 LPA Flores conducted an initial annual visit. During today's visit LPA completed the following CARE inspection tool domains Infection Control, Operational Requirements, Personnel Records/Staff Training, Resident Rights/Information, Incidental Medical and Dental, Resident Records/Incident Reports, Residents with Special Health Needs. LPA reviewed Emergency Disaster Plan last reviewed on 6/13/24 and Infection Control Plan last reviewed on 6/14/24. Last fire drill was conducted on 5/7/24. Staff have completed 20 hours of training. Hospice files are in place for those residents on hospice. LPA reviewed medication and files for 10 residents and 10 staff. Staff #8 and #9 were missing a TB test and Staff #11 did not have a background clearance. Interview 5 residents and 5 staff. LPA obtained a copy of liability insurance. Administrator certificate was observed for Shaun Rushforth 7006201740 exp. date: 9/17/24. Deficiencies are noted on LIC 809D per Title 22 Regulations. This visit concludes the annual visit for the facility. Exit interview was conducted with Lavern Villarba and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 18, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Aura Molina and Lavern Villarba Care Service Manager and explained the reason for the visit. Shaun Rushforth arrived 10 minutes later. 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 has a commercial kitchen, a swimming pool a gym, a dining room, library, different common areas in the 1st, 3rd, and 5th floor, and a dementia unit with delay egress system. LPA Flores conducted a tour of the facility with Aura Molina and Lavern Villarba and observed the following: Facility is in good repair indoor and outdoor. Passageways and emergency exits are cleared. Facility has a sprinkler emergency system throughout. Commercial kitchen is clean, in good repair, Refrigerators and pantry were observed with sufficient food for at least 2 days of perishables and 7 days of non-perishables. All common areas were observed in good repair. Fireplaces are covered. LPA observed 17 resident rooms each is furnished, with sufficient lighting, in good repair. Bathrooms were observed with grab bars, 6 assisted living out of the 17 bedrooms observed did not have skid mat/strips and tested the water temperature in each room between 109.0 - 118.9 degrees F., which is within the required temperature of 105-120 degrees F.Dementia unit is accessible with a code, each egress door was tested and are in working condition. Dementia unit has a secured outdoor area. 2 out of the 17 resident rooms observed were in dementia unit. In room #164 a bottle of cleaning solution was observed accessible to the resident. Facility has a pool/jacuzzi area which has a 5ft fence surrounding it and is accessible with a key card pad lock. Fire extinguishers were observed throughout the facility and last checked on 12/7/23. Evacuation chairs were observed on top of each stairway. Elevators were in working condition. During this visit LPA completed the following CARE inspection tool domains: Physical Plant/Environmental Safety Planned Activities, and Food Service. (CONTINUED ON LIC 809C) LPA will return at a different date to continue annual inspection due to time restrains. Deficiencies were noted during this visit per Title 22 Regulations. Exit interview was conducted with Shaun Rushforth and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 13, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit at the facility regarding incident report and SOC 341 submitted to the department on 1/3/24. LPA met with Marie Brooks and explained the reason for the visit. On 1/3/24 LPA Flores received Incident Report and SOC 341 from facility reporting the following: On 1/3/24 Resident #1(R1) reported that a facility staff (S1) that an individual had attempted to assault her. Upon Administrator and staff further questioning R1, R1 stated that a month or two months ago Staff #1(S1) had told R1 "was going to rape" R1. In addition had heard S1 tell another staff about two nights ago of S1 intentions of rape. This was heard in R1's apartment. Then R1 continue to state that 2 weeks ago S1 had come into the room and fiddle with R1's clothes, upon R1 elbowing S1 left the room.Facility submitted Report of Suspected Dependent Adult/Elder Abuse to the following agencies; Pasadena Police Department, Ombudsman, Community Care Licensing on 1/3/24. Officer Patarino conducted a visit to the facility on 1/3/24 regarding the allegation. The facility proceeded as follow: On 1/3/24 facility communicated with R1's physician regarding above allegation for medical care. On 1/5/24, per physician's order submitted a request for a psychological evaluation, updated R1's service plan, and conducted an internal investigation. Review of staff entering R1's room was conducted from 12/3/23-1/4/24. LPA reviewed R1's and S1's files and requested copies of the following documents for R1:Resident's service plan updated on 1/5/24, Facility Communication to Physician dated 1/3/24. Physician's request dated 1/3/24, Resident Appraisal dated 1/5/24, Physician's Report dated 1/10/23, Face Sheet. Copies of Application for Employment, Personal Action, Form, and Emergency Contact Information update were obtained for S1. Per physician's report R1 is ambulatory and capable of self care. Per administrator R1 is an independent resident with some assist. Police officer notified administrator that case will be forward to detective unit. LPA was unable to interview R1 due to quarantine guidelines and S1 was not schedule on shift. No Deficiencies are noted during this visit. Exit interview was conducted with Marie Brooks and a copy of report was provided.the state’s words, verbatim · CDSS document, Jan 18, 2024