Villa Gardens Health Care Unit

Name: Villa Gardens Health Care Unit
Address: 842 EAST VILLA STREET, Pasadena, CA, 91101, US
Telephone: 6267968162

842 East Villa Street, Pasadena, CA 91101 · Los Angeles County · 54 certified beds · avg 44 residents/day · certified since Jul 31, 1990

Part of chain: FRONT PORCH (9 facilities, chain avg rating 4.8★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

5.15

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (31)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Dec 5, 2025	F · Potential for harm, facility-wide	The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Dec 5, 2025	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Dec 5, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 5, 2025	E · Potential for harm, repeated	The facility did not dispose of garbage and refuse properly.
Dec 5, 2025	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Dec 5, 2025	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Dec 5, 2025	D · Potential for harm, one-off	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Oct 4, 2024	E · Potential for harm, repeated	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Oct 4, 2024	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 4, 2024	E · Potential for harm, repeated	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Oct 4, 2024	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 4, 2024	E · Potential for harm, repeated	The facility did not dispose of garbage and refuse properly.
Oct 4, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Oct 4, 2024	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Oct 4, 2024	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Oct 4, 2024	D · Potential for harm, one-off	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
Jan 31, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 31, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 8, 2023	E · Potential for harm, repeated	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Oct 8, 2023	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 8, 2023	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Oct 8, 2023	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Oct 8, 2023	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 8, 2023	E · Potential for harm, repeated	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Oct 8, 2023	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Oct 8, 2023	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Oct 8, 2023	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 24, 2023	E · Potential for harm, repeated	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint
Aug 24, 2023	E · Potential for harm, repeated	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (9 → 9).

Year	Citations	Worst severity that year
2023	11	E
2024	11	E
2025	9	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	5.15	4.31	3.95	top 12% in California; top 11% in the U.S.
Registered Nurse hours	0.56	0.61	0.69	top 38% in California; bottom 46% in the U.S.
Weekend total nurse staffing	4.57	3.90	3.50	top 12% in California; top 11% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.40	0.51	0.48	top 45% in California; top 48% in the U.S.
Total nursing staff turnover (%)	21.8	36.7	45.8	top 11% in California; top 4% in the U.S.
RN turnover (%)	0.0	38.1	42.9	—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.06, RN 0.55, weekend 4.48. Staffing rating: 5/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
Front Porch Communities and Services	Organization	5% or Greater Direct Ownership Interest	100%	10/01/2006
Akopyan, Gevork	Individual	Operational/Managerial Control	NOT APPLICABLE	10/12/2022
Dudley, Leslie	Individual	Operational/Managerial Control	NOT APPLICABLE	07/01/2022
Dudley, Leslie	Individual	ADP of the SNF	NOT APPLICABLE	07/01/2022
Duranteau, Nancy	Individual	Corporate Director	NOT APPLICABLE	04/01/2021
Forte, Vincent	Individual	Corporate Director	NOT APPLICABLE	04/01/2021
Handy, Joanne	Individual	Corporate Director	NOT APPLICABLE	04/01/2021
Jackson, Karlisa	Individual	Operational/Managerial Control	NOT APPLICABLE	12/29/2023
Jacobs, Laura	Individual	Corporate Director	NOT APPLICABLE	01/01/2019
Kelly, Sean	Individual	Corporate Officer	NOT APPLICABLE	03/06/2023
Kelly, Sean	Individual	Operational/Managerial Control	NOT APPLICABLE	03/06/2023
Kroeker, Kevin	Individual	Corporate Director	NOT APPLICABLE	01/01/2018
Macango, Susan	Individual	Operational/Managerial Control	NOT APPLICABLE	05/04/2026
McGovern, Marion	Individual	Corporate Director	NOT APPLICABLE	01/01/2017
McMullin, Mary	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2025
Merkin, Nickolas	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	09/30/2025
Nelson, Harry	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	09/30/2025
Niblett, Joel	Individual	Operational/Managerial Control	NOT APPLICABLE	04/17/2026
Niblett, Joel	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2026
Olson, Kari	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2001

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How many hours a day is a registered nurse physically in the building, including weekends?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Can I see where garbage is stored and how often it's removed?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Pasadena Grove Health Center	1.6 mi	Pasadena, CA	★★☆☆☆	2/5
Foothill Heights Care Center	1.7 mi	Pasadena, CA	★★★☆☆	3/5
Pasadena Nursing Center	1.7 mi	Pasadena, CA	★★☆☆☆	2/5	abuse
Cedar Pine Post Acute	1.8 mi	Pasadena, CA	★★☆☆☆	1/5	abuse
Gem Tcu	1.8 mi	Pasadena, CA	★☆☆☆☆	1/5
The Californian Pasadena Healthcare	1.9 mi	Pasadena, CA	★★★☆☆	3/5
The Bellefontaine Healthcare Center	1.9 mi	Pasadena, CA	★★★☆☆	2/5
Saint Vincent Healthcare	1.9 mi	Pasadena, CA	★★★☆☆	4/5
Brighton Care Center	2.0 mi	Pasadena, CA	★★☆☆☆	2/5
Pasadena Park Healthcare and Wellness Center	2.0 mi	Pasadena, CA	★★☆☆☆	3/5
Golden Rose Care Center	2.0 mi	Pasadena, CA	★☆☆☆☆	1/5	SFF
Camellia Gardens Care Center	2.0 mi	Pasadena, CA	★★☆☆☆	3/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 555429.

The Care File

Visit checklist — Villa Gardens Health Care Unit

842 East Villa Street, Pasadena, CA 91101 · 6267968162

Health inspection rating 3/5 · CMS overall 5/5· Fines (3y): $0

Questions for the administrator:

☐ "How many hours a day is a registered nurse physically in the building, including weekends?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Can I see where garbage is stored and how often it's removed?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 555429 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)