Inspection Reports for
Villa Gardens
842 EAST VILLA STREET, PASADENA, CA, 91101
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
6% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 19
Capacity: 340
Deficiencies: 1
Date: Nov 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff caused injury to a resident.
Complaint Details
The complaint alleged that staff caused injury to a resident by pinching the resident's nose, causing a bruise. The allegation was substantiated based on interviews with staff and residents, review of injury photo, and admission by the staff member involved.
Findings
The investigation substantiated the allegation that a staff member (S2) grabbed a resident's nose causing a bruise. The staff member admitted to the action, was placed off schedule, and subsequently terminated. The facility provided in-service training on personal rights and abuse to all staff.
Deficiencies (1)
Failure to ensure residents are free from punishment, humiliation, intimidation, abuse, or other punitive actions, evidenced by staff grabbing a resident's nose causing injury.
Report Facts
Staff interviewed: 8
Residents interviewed: 5
Deficiency Type A count: 1
Capacity: 340
Census: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shaun Rushforth | Administrator | Met with Licensing Program Analyst during investigation |
| Alex Alvarado | Director of Health Services | Met with Licensing Program Analyst during investigation |
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Supervisor | Supervisor overseeing the investigation |
| S2 | Staff member | Admitted to grabbing resident's nose causing injury; terminated |
| S3 | Staff member | Witnessed S2 grabbing resident's nose |
Inspection Report
Annual Inspection
Census: 233
Capacity: 340
Deficiencies: 0
Date: May 27, 2025
Visit Reason
An unannounced case management - annual continuation visit was conducted using the CARE inspection tool to review compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies noted during this visit. Infection control, staffing, personnel records, and planned activities were reviewed and found satisfactory. Special health needs of residents were addressed appropriately.
Report Facts
Residents on hospice: 11
Bedridden residents: 1
Staff files reviewed: 10
Pendant call buttons tested: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shaun Rushforth | Administrator | Met during inspection and named in staffing review |
| Alex Alvarado | Director of Health Services | Met during inspection and explained reason for visit |
| Mary G Flores | Licensing Program Analyst | Conducted the inspection |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 233
Capacity: 340
Deficiencies: 2
Date: May 9, 2025
Visit Reason
An unannounced annual visit was conducted using the CARE inspection tool to evaluate compliance with licensing requirements for the Continuing Care Residential Community facility.
Findings
The facility was generally found to be in good repair and operating within license limitations, but deficiencies were noted including water temperature exceeding regulatory limits in 2 rooms and missing skid mats in 9 residents' showers, posing potential or immediate health and safety risks.
Deficiencies (2)
Water temperature in resident rooms #207 and #105 exceeded the required maximum of 120 degrees F, posing an immediate health, safety, or personal rights risk.
Nine residents' showers in rooms 553, 536, 542, 424, 403, 408, 240, 210, and 160/167 were missing skid mats or strips, posing a potential health, safety, or personal rights risk.
Report Facts
Residents under hospice: 6
Bedridden residents: 1
Rooms inspected for water temperature: 24
Rooms missing skid mats: 9
Residents' medication files reviewed: 10
Residents' records reviewed: 10
Residents interviewed: 6
Emergency drills conducted quarterly: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shaun Rushforth | Administrator | Met with Licensing Program Analysts during inspection and named in findings |
| Mary G Flores | Licensing Program Analyst | Conducted inspection and signed report |
| Tony Vasallo | Licensing Program Manager | Named in report and deficiency sections |
Inspection Report
Annual Inspection
Census: 236
Capacity: 340
Deficiencies: 2
Date: Jun 18, 2024
Visit Reason
The inspection was an unannounced continuation annual visit conducted using the CARE inspection tool to evaluate compliance with regulatory requirements.
Findings
The inspection identified deficiencies related to missing background clearance for one staff member and missing TB tests for two staff members. Civil penalties were assessed for the background clearance deficiency, and plans of correction were required.
Deficiencies (2)
One staff member did not have a background clearance, posing an immediate health, safety, or personal rights risk to persons in care.
Two staff members did not have TB clearance on file, posing a potential health, safety, or personal rights risk to persons in care.
Report Facts
Civil penalty amount: 500
Staff reviewed for TB clearance: 10
Residents reviewed for medication and files: 10
Staff reviewed for medication and files: 10
Hours of staff training completed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shaun Rushforth | Administrator | Administrator certificate observed and named in plan of correction |
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Aura Molina | Nurse Assistant Lead | Met with the Licensing Program Analyst during the inspection |
Inspection Report
Annual Inspection
Census: 236
Capacity: 340
Deficiencies: 2
Date: Jun 13, 2024
Visit Reason
Licensing Program Analyst Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool to evaluate compliance with regulations.
Findings
The facility was generally found to be in good repair with cleared passageways, functional safety systems, and sufficient food supplies. However, deficiencies were noted including accessible cleaning solution in a resident room and lack of skid mats in several showers.
Deficiencies (2)
Cleaning solution accessible to resident in room #164 in the dementia unit posing an immediate health, safety or personal rights risk.
Six out of 17 resident showers observed without skid mats or strips in rooms #164, 161, 257, 253, 207, and 413 posing a potential health, safety or personal rights risk.
Report Facts
Residents observed without skid mats: 6
Residents observed in dementia unit: 2
Licensed capacity: 340
Current census: 236
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and signed the report |
| Shaun Rushforth | Administrator | Facility administrator present during inspection and exit interview |
| Aura Molina | Nurse Assistant Lead | Met with Licensing Program Analyst during inspection |
| Lavern Villarba | Care Service Manager | Met with Licensing Program Analyst during inspection |
| Tony Vasallo | Supervisor | Supervisor named in report |
Inspection Report
Complaint Investigation
Census: 226
Capacity: 340
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
An unannounced case management visit was conducted regarding an incident report and SOC 341 submitted on 2024-01-03 concerning allegations of attempted assault and inappropriate conduct by a staff member towards a resident.
Complaint Details
The complaint involved Resident #1 alleging that a staff member had threatened and attempted to assault her. The facility submitted reports to the Pasadena Police Department, Ombudsman, and Community Care Licensing. The resident's physician was contacted and a psychological evaluation was requested. The licensing analyst was unable to interview the resident due to quarantine and the staff member was not on shift during the visit.
Findings
The facility reported the incident to appropriate agencies and conducted an internal investigation including review of staff entries. No deficiencies were noted during this visit. The police notified the administrator that the case will be forwarded to the detective unit.
Report Facts
Capacity: 340
Census: 226
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Marie Brooks | Wellness Director | Met with Licensing Program Analyst during the visit |
| Shaun Rushforth | Administrator | Facility administrator involved in questioning and case management |
Inspection Report
Complaint Investigation
Census: 237
Capacity: 340
Deficiencies: 0
Date: Aug 29, 2023
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff spoke inappropriately to a resident in care.
Complaint Details
The complaint alleged that staff spoke inappropriately to a resident, specifically that the administrator went on a 'rant' and stormed out of a meeting. Interviews with residents and staff did not substantiate the allegation.
Findings
The investigation found that 9 out of 10 residents stated the administrator was respectful and calm when communicating, while 1 resident felt the administrator walked away without resolution. The administrator explained walking away was a professional decision to de-escalate the conversation. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 10
Staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shaun Rushforth | Administrator | Named in allegation and interview regarding staff communication with residents |
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 236
Capacity: 340
Deficiencies: 0
Date: Jun 10, 2023
Visit Reason
The inspection was an unannounced case management visit as part of the annual continuation to review various domains including personnel records, resident records, infection control, residents with special needs and health needs, and incidental medical and dental.
Findings
No deficiencies were observed during this visit. The Licensing Program Analyst reviewed files and conducted interviews with 5 residents and 5 staff. An administrator certificate for Shaun Rushforth was observed and valid.
Report Facts
Number of residents interviewed: 5
Number of staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shaun Rushforth | Administrator | Administrator certificate observed and mentioned in the report |
| Mary Flores | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Annual Inspection
Census: 236
Capacity: 340
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
Licensing Program Analyst Mary Flores conducted an unannounced annual visit at the facility using the CARE tool to evaluate compliance with regulations.
Findings
The facility was found to be clean and in good repair with sufficient food supplies and appropriate safety measures. However, a deficiency was noted for improper storage of cleaning solution in a resident's bathroom, posing a health and safety risk.
Deficiencies (1)
Cleaning solution was observed next to the toilet in room #245, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Residents' medication reviewed: 10
Food supplies duration: 2
Food supplies duration: 7
Residents observed in bedrooms: 17
Water temperature range: 109.8
Water temperature range: 118.9
Fire drill date: May 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the unannounced annual inspection and authored the report. |
| Shaun Rushforth | Administrator | Facility administrator present during the inspection and exit interview. |
Inspection Report
Annual Inspection
Capacity: 340
Deficiencies: 1
Date: Jun 17, 2022
Visit Reason
Licensing Program Analyst Mary Flores conducted an unannounced annual visit focusing on infection control, medication, and food supplies at the facility.
Findings
The facility was found to have sufficient food supplies and appropriate water temperatures in resident rooms; however, a deficiency was noted due to the freezer temperature being at 20 degrees F instead of the required 0 degrees F, posing a potential health risk.
Deficiencies (1)
Freezer temperature was observed at 20 degrees F, not maintaining the required 0 degrees F, posing a potential health, safety, or personal rights risk to persons in care.
Report Facts
Capacity: 340
Plan of Correction Due Date: Jun 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the unannounced annual visit and evaluation |
| Daisy Abarrientos | Wellness Director | Met with Licensing Program Analyst during the inspection and exit interview |
Inspection Report
Annual Inspection
Census: 128
Capacity: 340
Deficiencies: 0
Date: Nov 2, 2021
Visit Reason
The visit was a case management continuation annual review to assess medication management and COVID-19 staff training compliance at the facility.
Findings
The Licensing Program Analysts reviewed medication for multiple residents and found the facility in compliance. The facility also provided monthly COVID-19 staff training updates for 2020 and 2021.
Report Facts
Residents reviewed for medication: 22
Residents independent of medication handling: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paula Digerness | Administrator | Met with Licensing Program Analysts during the visit |
| Mary Flores | Licensing Program Analyst | Conducted the case management continuation visit |
| Jewel Baptiste | Licensing Program Analyst | Conducted the case management continuation visit |
| Rebecca Orendain | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Plan of Correction
Capacity: 340
Deficiencies: 1
Date: Nov 2, 2021
Visit Reason
Licensing Program Analysts conducted a plan of correction visit to verify correction of deficiencies given on 10/22/2021.
Findings
The deficiency related to storage space of PRN medication and cleaning supplies observed on 10/22/2021 was cleared during this visit. A lock cabinet was observed under the bathroom sink in room #529, and additional cleaning items were moved to the cabinet. PRN medication stored in resident's room #529 will be kept under lock.
Deficiencies (1)
Storage Space - PRN medication and cleaning supplies improperly stored in rooms #215 and #529.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted plan of correction visit and gave deficiency on 10/22/21. |
| Jewel Baptiste | Licensing Program Analyst | Conducted plan of correction visit. |
| Daisy Abarrientos | Wellness Director | Moved additional cleaning items to locked cabinet during visit. |
| Paula Digerness | Administrator | Participated in exit interview. |
Inspection Report
Annual Inspection
Census: 340
Capacity: 340
Deficiencies: 1
Date: Oct 22, 2021
Visit Reason
An unannounced annual visit was conducted focusing on infection control, medication, and food review at the facility.
Findings
The facility was found to have infection control deficiencies including staff not properly wearing masks and accessible cleaning supplies in resident rooms. Deficiencies were cited under Title 22 Division 6 Chapter 8 and a plan of correction was required.
Deficiencies (1)
Cleaning supplies were accessible to residents in 2 out of 20 rooms observed, posing an immediate health and safety risk.
Report Facts
Residents licensed capacity: 340
Residents census: 340
Hospice residents: 18
Plan of Correction due date: Oct 25, 2021
Rooms observed: 20
Rooms with accessible cleaning supplies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Paula Digerness | Administrator | Facility administrator met during inspection and exit interview |
| Rebecca Orendain | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 214
Capacity: 340
Deficiencies: 0
Date: Sep 29, 2021
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that residents engaged in a physical altercation due to lack of supervision.
Complaint Details
The allegation of residents engaging in a physical altercation due to lack of supervision was investigated and found to be unfounded.
Findings
The investigation found that the residents involved in the allegation did not reside at the facility, and based on the information gathered, the allegation was deemed unfounded.
Report Facts
Capacity: 340
Census: 214
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Paula Digerness | Administrator | Met with investigators during the complaint investigation |
Report
December 5, 2025
Report
October 4, 2024
Report
January 31, 2024
Report
October 8, 2023
Report
August 24, 2023
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