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Villa Gardens Health Center is a 340-bed skilled nursing facility at 842 East Villa Street, Pasadena, Los Angeles County, California, administered by Shaun Rushforth and licensed by the California Department of Social Services, Community Care Licensing Division. The facility serves non-ambulatory seniors 65 and over, including residents on hospice care and those in a secured dementia unit. Current occupancy is 6 percent (19 beds occupied), well below the California average of 72.8 percent.
The most pressing concern is recent substantiated harm. In November 2025, the licensing agency substantiated a complaint that a staff member pinched a resident’s nose on October 26, 2025, causing visible bruising. The staff member was removed from duty on October 27 and terminated on November 10. The facility provided mandatory in-service training on personal rights and abuse prevention.
This incident, combined with an earlier sexual assault allegation investigated in January 2024 (forwarded to law enforcement), signals potential gaps in staff screening, supervision, or conduct standards.
The inspection record reveals a pattern of safety violations. Since 2021, the facility has been cited for 6 Type A (immediate risk) and 4 Type B (potential risk) violations across 14 regulatory visits. Most striking is the recurrence of storage and chemical accessibility deficiencies in October 2021, June 2023, and June 2024; three times in four years residents or staff found cleaning solutions accessible in patient rooms and dementia units. Each was classified as an immediate health hazard.
In June 2024, an inspection found non-skid mats missing in 6 of 17 observed showers. Personnel compliance gaps emerged in the same period: one staff member was employed without background clearance (civil penalty of $500 imposed), and two staff lacked required TB testing documentation.
Staffing composition reflects significant variation against state benchmarks. Registered nurse hours average 20 minutes per resident per day, 49 percent below California’s standard of 39 minutes. Weekend RN coverage is particularly weak at 12 minutes daily, 60 percent below the state average of 30 minutes, reducing clinical oversight when administrative staff are typically absent. Licensed Practical Nurse hours are strong at 1 hour 46 minutes daily, 45 percent above state average.
Certified Nurse Aide coverage is 3 hours 4 minutes per day, 16 percent above the state benchmark. Weekend nursing totals 4 hours 39 minutes per day, meeting state average.
Quality measures for current residents show markedly positive outcomes. Long-stay hospitalizations occur at 1.17 per 1,000 days versus California’s 2.25; a 48 percent improvement. Long-stay emergency department visits are 0.20 per 1,000 days compared to the state average of 1.59, representing an 87 percent reduction. Short-stay re-hospitalization is 19.4 percent versus California’s 23.2 percent.
Successful return to home or community reaches 63.5 percent, 26 percent better than the state average of 50.6 percent. The facility’s short-stay quality measure rating is significantly above average, and long-stay measures are above average. These strong outcomes must be weighed against the facility’s extremely low occupancy and the substantiated recent incident.
The facility operates under California licensing requirements with current administrator certification and staff training documentation. Recreational amenities include a secured swimming pool (five-foot fence, key card access), gym, library, and dementia-specific activity programming. A commercial kitchen maintains food service logs and temperature protocols. The facility is located 1.2 miles from Pasadena’s downtown (Walk Score 79, very walkable) and 5.4 miles from the nearest hospital.
Families should ask about the scope of corrections for the October 2025 physical injury incident, and documentation of the January 2024 investigation outcome.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 20m per day | ▼ 49% State avg: 39m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 1h 46m per day | ▲ 45% State avg: 1h 13m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 3h 4m per day | ▲ 16% State avg: 2h 39m per day · National avg: 2h 21m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 4h 39m per day | ▲ 14% State avg: 4h 5m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 8m per day | ▲ 60% State avg: 5m per day · National avg: 4m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 12m per day | ▼ 60% State avg: 30m per day · National avg: 29m per day |
Villa Gardens Health Center is legally operated by Front Porch Communities And Services, and administrated by Shaun Rushforth.
In California, the Department of Social Services (for assisted living facilities) and the Department of Public Health (for nursing homes) conduct inspections to ensure resident safety and regulatory compliance.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the California state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Citations
| This Facility | CA Average | vs. CA Avg |
|---|---|---|---|
|
Total citations
Formal regulatory issues recorded by inspectors across all inspection types.
| 10 | 10 | This facility has total citations in line with the California average (10 vs. CA avg 10).— At avg |
|
Serious citations (Type A)
Violations that pose an immediate risk to resident health or safety. Type A citations are the most serious and typically require prompt corrective action.
| 6 | 3 | This facility has 100% more serious citations (type a) than a typical California nursing home (6 vs. CA avg 3).↑ 100% worse |
|
Moderate citations (Type B)
Violations that do not pose an immediate risk but still represent a departure from required care or operational standards.
| 4 | 4 | This facility has moderate citations (type b) in line with the California average (4 vs. CA avg 4).— At avg |
|
Citations per year
Average citations per year since 2021.
| 2 | 2 | This facility has citations per year in line with the California average (2 vs. CA avg 2).— At avg |
|
Citations per inspection
Average citations per inspection.
| 0.7 | 3.3 | This facility has 79% fewer citations per inspection than a typical California nursing home (0.7 vs. CA avg 3.3).↓ 79% better |
Inspections & Visits
| This Facility | CA Average | vs. CA Avg |
|---|---|---|---|
|
Total visits
Combined count of complaint visits, other regulatory visits, and official scheduled inspections.
| 14 | 16 | This facility has 13% fewer total visits than a typical California nursing home (14 vs. CA avg 16).↓ 13% better |
|
Complaint visits
On-site visits triggered by formal complaints filed by residents, families, or staff.
| 3 | 13 | This facility has 77% fewer complaint visits than a typical California nursing home (3 vs. CA avg 13).↓ 77% better |
|
Other visits
Regulatory visits that are neither routine inspections nor complaint investigations — administrative check-ins, follow-up reviews, licensing-related visits.
| 6 | 7 | This facility has 14% fewer other visits than a typical California nursing home (6 vs. CA avg 7).↓ 14% better |
|
Official inspections
Routine, scheduled inspections conducted by state regulators to evaluate whether the facility meets federal and state standards.
| 5 | 4 | This facility has 25% more official inspections than a typical California nursing home (5 vs. CA avg 4).↑ 25% worse |
|
Complaint investigations
On-site investigations triggered by complaints filed with California regulators.
| 3 | 10 | This facility has 70% fewer complaint investigations than a typical California nursing home (3 vs. CA avg 10).↓ 70% better |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
Villa Gardens Health Care Unit’s inspection record is mixed, showing repeated deficiencies in medication administration, infection control, food safety, and environmental hazards across multiple inspections. The most recent inspection on December 5, 2025, cited nine deficiencies including medication errors, lack of RN coverage, unsanitary conditions, uncovered dumpsters, and failure to implement antibiotic stewardship. A January 31, 2024 complaint investigation substantiated failures in wound care documentation and unsafe environment causing injury, indicating ongoing safety and care concerns.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsThese measures show how residents usually do over time at this home, based on health outcomes and preventive care.
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Number of hospitalizations per 1,000 long-stay resident days.
1.17
48% better than California averageCalifornia average: 2.25
Number of outpatient emergency department visits per 1,000 long-stay resident days.
0.20
87% better than California averageCalifornia average: 1.59
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
19.4%
16% better than California averageCalifornia average: 23.2%
Percentage of short-stay residents who had an outpatient emergency department visit.
3.3%
71% better than California averageCalifornia average: 11.2%
Percentage of SNF residents who experience falls with major injury during their stay.
0.5%
34% better than California averageCalifornia average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
52.1%
In line with California averageCalifornia average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
63.5%
26% better than California averageCalifornia average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
1.2 miles from city center
Estimated distance in miles from Pasadena's city center to Villa Gardens Health Center's address, calculated via Google Maps.
— 5.41 miles to nearest hospital (USC Arcadia Hospital)
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Villa Gardens Health Center is located in Pasadena, California.
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The information below is reported by the California Department of Social Services and Department of Public Health.
| The Oaks of Pasadena |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support. | Pasadena (Lamanda Park) | 49 | 90.3% | +7% | 3.57 | -10% | -15% | $0 | 23 | 5.8 | - | 47 | 70 | Ian Cook | $13.5M | $5.2M | 38.1% | 55085 | ||||
| Villa Gardens Retirement Community |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
IL Independent Living Lifestyle-focused communities for older adults offering dining, activities, and transportation with minimal personal care. Best for active, independent seniors who want community without medical support.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk.
N Nursing | Pasadena (East Villa Street) | 340 | 5.6% | -93% | 3.57 | -23% | -15% | $40.7k | 65 | 5.0 | 4 | 93 | 79 | Providence Group Of California LLC | $12.8M | $6.3M | 48.9% | 55551 | ||||
| Summer House at Villa Garden |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Pasadena (East Villa Street) | 99 | 91.6% | +8% | 3.57 | -23% | -15% | $40.7k | 65 | 5.0 | 4 | 93 | 79 | Providence Group Of California LLC | $12.8M | $6.3M | 48.9% | 55551 | ||||
| Pasadena Nursing Center |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
RC Respite Care Short-term temporary care — days to weeks — to give family caregivers a break. Full care provided during the stay. Often used after hospitalization or to trial a facility before a permanent placement decision. | Pasadena (North Central) | 108 | 75.0% | -11% | 4.14 | -3% | -2% | $38.2k | 85 | 4.3 | 4 | 81 | 64 | Gardena Retirement Center, Inc. | $8.9M | $5.0M | 56.3% | 555213 |
Villa Gardens Health Center is in the East Villa Street neighborhood of Pasadena.
The legal owner and operator of Villa Gardens Health Center is Front Porch Communities And Services.
Villa Gardens Health Center has a walk score of 79. Very walkable. Most errands can be accomplished on foot, and many essentials are within a short walk.
Villa Gardens Health Center's occupancy is 5.6%.
Shaun Rushforth is the administrator of Villa Gardens Health Center.
Villa Gardens Health Center has 340 beds.
Villa Gardens Health Center has had 10 recently reported deficiencies.
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