Federal inspection record · CMS data as of October 1, 2026
Villa Gardens Health Care Unit
842 East Villa Street, Pasadena, CA · (626) 796-8162
- CMS high-performer trophy
- Certified beds
- 54
- Residents per day
- 43
- Ownership
- Non-Profit
- Chain
- Front Porch
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 31, 1990
1
How this home got 5 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in California.
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Staffing
★★★★★+1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change (already 5)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★5 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among California homes
Villa Gardens Health Care Unit carries 65 inspection points. That is fewer than 67% of California's 1,154 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in California: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–33 pts
- 4★ 33–66 pts
- 3★ 66–96 pts
- 2★ 96–146 pts
- 1★ over 146 pts
Bars show every rated home in California by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
29 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care6E
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nutrition and Dietary5E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Dispose of garbage and refuse properly.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Dispose of garbage and refuse properly.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control5E
- E
Provide and implement an infection prevention and control program.
- D
Implement a program that monitors antibiotic use.
- E
Provide and implement an infection prevention and control program.
- E
Implement a program that monitors antibiotic use.
- D
Provide and implement an infection prevention and control program.
Pharmacy Service4E
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure medication error rates are not 5 percent or greater.
- E
Ensure medication error rates are not 5 percent or greater.
- E
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.
Resident Rights3E
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- D
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.
- E
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.
Resident Assessment and Care Planning3E
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Nursing and Physician Services1F
- F
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.
Environmental1D
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Administration1D
- D
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.
Inspection history
2025-12-05
9 health deficiencies · 7 fire-safety deficiencies
Top issue: Infection Control (2 deficiencies)
2024-10-04
9 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2023-10-08
11 health deficiencies · 15 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 5 h 16 min of nursing staff time a day, 37 min of it from a registered nurse.
This home
5 h 16 min
California average
4 h 33 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 24% of nursing staff and 0% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.4 pts better | 1.8 | 2.2 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.5 pts better | 0 | 1.5 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.3 pts better | 100.0% | 98.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.1 pts better | 100.0% | 97.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.6 pts better | 0.0% | 1.6% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms7.6 pts better | 0.0% | 7.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.8 pts better | 2.3% | 4.1% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication1.7 pts worse | 15.4% | 13.7% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication8.4 pts better | 3.9% | 12.3% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.3 pts better | 0.0% | 0.3% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened14.7 pts worse | 23.6% | 8.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3 pts worse | 13.2% | 10.2% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.5 pts worse | 2.2% | 0.7% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection1 pts worse | 2.2% | 1.2% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence8.5 pts worse | 18.3% | 9.8% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2 pts better | 2.3% | 4.3% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine5.2 pts better | 99.8% | 94.6% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit9 pts better | 2.1% | 11.1% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.7 pts better | 0.6% | 1.3% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine6.9 pts better | 100.0% | 93.1% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission2.6 pts better | 20.0% | 22.6% | 23.4% |
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Who owns and runs it
30 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Front Porch Communities And Services | 5% Or Greater Direct Ownership Interest · Organization | 100% | 9 facilities |
| Akopyan, Gevork | Operational/Managerial Control · Individual | 0% | 9 facilities |
| Dudley, Leslie | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Dudley, Leslie | Adp Of The SNF · Individual | 0% | 1 facilities |
| Duranteau, Nancy | Corporate Director · Individual | 0% | 9 facilities |
| Forte, Vincent | Corporate Director · Individual | 0% | 9 facilities |
| Handy, Joanne | Corporate Director · Individual | 0% | 14 facilities |
| Jackson, Karlisa | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Jacobs, Laura | Corporate Director · Individual | 0% | 9 facilities |
| Kelly, Sean | Corporate Officer · Individual | 0% | 9 facilities |
| Kelly, Sean | Operational/Managerial Control · Individual | 0% | 9 facilities |
| Kroeker, Kevin | Corporate Director · Individual | 0% | 9 facilities |
| Macango, Susan | Operational/Managerial Control · Individual | 0% | 9 facilities |
| Mcgovern, Marion | Corporate Director · Individual | 0% | 9 facilities |
| Mcmullin, Mary | Operational/Managerial Control · Individual | 0% | 9 facilities |
| Merkin, Nickolas | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 6 facilities |
| Nelson, Harry | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 6 facilities |
| Niblett, Joel | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Niblett, Joel | Adp Of The SNF · Individual | 0% | 1 facilities |
| Olson, Kari | Operational/Managerial Control · Individual | 0% | 9 facilities |
| Pennington, Paige | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 6 facilities |
| Rushforth, Shaun | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Salvador, Eduardo | Corporate Officer · Individual | 0% | 9 facilities |
| Salvador, Eduardo | Operational/Managerial Control · Individual | 0% | 9 facilities |
| Spencer, Peter | Corporate Director · Individual | 0% | 9 facilities |
| Sumner, Craig | Operational/Managerial Control · Individual | 0% | 3 facilities |
| Tonnu, Diemlan | Corporate Director · Individual | 0% | 9 facilities |
| Vranich, Rachel | Corporate Officer · Individual | 0% | 9 facilities |
| Wesson, Oliver | Corporate Director · Individual | 0% | 9 facilities |
| Whittaker, Susan | Corporate Director · Individual | 0% | 9 facilities |
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Fire safety
24 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke12F
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- D
Install corridor and hallway doors that block smoke.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Have properly installed hallway dispensers for alcohol-based hand rub.
- E
Construct fire resistant interior walls.
- E
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- D
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- D
Install an approved automatic sprinkler system.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
Gas, Vacuum, and Electrical Systems5F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure proper usage of power strips and extension cords.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- D
Ensure proper usage of power strips and extension cords.
- D
Have proper medical gas storage and administration areas.
Egress2F
- F
Have properly located and lighted "Exit" signs.
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Services2E
- E
Have properly installed electrical wiring and gas equipment.
- E
Have properly installed electrical wiring and gas equipment.
Emergency Preparedness2C
- C
Address subsistence needs for staff and patients.
- C
Implement emergency and standby power systems.
Miscellaneous1F
- F
Provide a written emergency evacuation plan.
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Pasadena Nursing Center
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