Cycle 1
Health 2025-12-05 · Fire 2025-12-05
9 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Pasadena, CA
Villa Gardens Health Care Unit
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
842 East Villa Street, Pasadena, CA
(626) 796-8162
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Front Porch
Operator or chain grouping
Approved since
1990-07-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing
LPN hours / resident day
1.77
Licensed practical nurse staffing
Aide hours / resident day
3.06
Nurse aide staffing
Weekend hours
4.65
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
20%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.6
1.4 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
1.6%
3.7 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.1%
0.6 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
13.7%
1.9 pts worse
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 1.5% |
14.2%
12.7 pts better
|
16.7%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.3% |
11.0%
20.3 pts worse
|
16.3%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.4% |
10.7%
10.7 pts worse
|
14.9%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.0%
0.7 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.2%
1 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
10.9%
15.3 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.7%
1.5 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
94.0%
4.1 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.3% |
11.2%
7.9 pts better
|
12.0%
8.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
93.2%
4.1 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
23.2%
3.8 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-04 · Fire 2024-10-04
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-10-08 · Fire 2023-10-08
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-12-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-02
F · Potential for more than minimal harm
2025-12-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-02
E · Potential for more than minimal harm
2025-12-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-12-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-02
D · Potential for more than minimal harm
2024-10-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-27
D · Potential for more than minimal harm
2024-10-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-27
F · Potential for more than minimal harm
2023-10-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-09
F · Potential for more than minimal harm
2023-10-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-08
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-08
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-08
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-09
E · Potential for more than minimal harm
2023-10-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-08
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-08
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-10-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-09
C · Minimal harm
2023-10-08
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-11-09
C · Minimal harm
2023-10-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-11-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-12-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-12-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-12-05
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-12-26
E · Potential for more than minimal harm
2025-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-05
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-12-26
E · Potential for more than minimal harm
2024-10-04
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-11-03
E · Potential for more than minimal harm
2024-10-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-03
E · Potential for more than minimal harm
2024-10-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-03
E · Potential for more than minimal harm
2024-10-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-03
E · Potential for more than minimal harm
2024-10-04
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-11-03
E · Potential for more than minimal harm
2024-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-04
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-10-04
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-11-03
D · Potential for more than minimal harm
2024-01-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-01
E · Potential for more than minimal harm
2023-10-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-10-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-10-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-10-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-10-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-10-08
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-10-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-10-08
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-10-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-30
E · Potential for more than minimal harm
2023-08-24
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-09-24
E · Potential for more than minimal harm
2023-08-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-24
Penalties and ownership
What sits behind the stars
Ownership
Front Porch Communities And Services
5% Or Greater Direct Ownership Interest · Organization
Akopyan, Gevork
Operational/Managerial Control · Individual
Cairns, Dawn
Operational/Managerial Control · Individual
Dudley, Leslie
Operational/Managerial Control · Individual
Duranteau, Nancy
Corporate Director · Individual
Forte, Vincent
Corporate Director · Individual
Handy, Joanne
Corporate Director · Individual
Herzig, Randy
Operational/Managerial Control · Individual
Jackson, Karlisa
Operational/Managerial Control · Individual
Jacobs, Laura
Corporate Director · Individual
Kelly, Sean
Operational/Managerial Control · Individual
Kelly, Sean
Corporate Officer · Individual
Kroeker, Kevin
Corporate Director · Individual
Mcgovern, Marion
Corporate Director · Individual
Mcmullin, Mary
Operational/Managerial Control · Individual
Olson, Kari
Operational/Managerial Control · Individual
Proctor, Deborah
Corporate Director · Individual
Rushforth, Shaun
Operational/Managerial Control · Individual
Salvador, Eduardo
Operational/Managerial Control · Individual
Salvador, Eduardo
Corporate Officer · Individual
Spencer, Peter
Corporate Director · Individual
Tonnu, Diemlan
Corporate Director · Individual
Vranich, Rachel
Corporate Officer · Individual
Wesson, Oliver
Corporate Director · Individual
Whittaker, Susan
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Pasadena Grove Health Center
Pasadena, CA
2-star overall rating with 2-star inspections with $4,233 in total fines with 24 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Foothill Heights Care Center
Pasadena, CA
3-star overall rating with 3-star inspections with $9,390 in total fines with 16 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Pasadena Nursing Center
Pasadena, CA
2-star overall rating with 2-star inspections with $23,160 in total fines with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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