Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
VILLA GARDENS HEALTH CARE UNIT
PASADENA, CA · 54 certified beds · Last Life Safety survey December 5, 2025
CMS Certification Number 555429 · first certified July 1990
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Villa Gardens (842 East Villa Street). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Operated by FRONT PORCH · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CA
24 citations — more than 67% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys in the window averaged 8.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens December 2026 — about 2 months from now. This facility’s last Life Safety survey was December 2025. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 24 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 24 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 24 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 8, 2023 | 15 |
| October 4, 2024 | 2 |
| December 5, 2025 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-12-05 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-12-05 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-12-05 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-12-05 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2024-10-04 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-12-05 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2023-10-08 |
| K-0331 | Construct fire resistant interior walls. | 1 | 2023-10-08 |
What the citations cover
- Smoke Deficiencies 12
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Emergency Preparedness Deficiencies 2
- Services Deficiencies 2
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 2 |
| Services Deficiencies | 2 |
| Egress Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 5, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (January 2, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 2, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 2, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 2, 2026) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 26, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 2, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 2, 2026) |
October 4, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 27, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 27, 2024) |
October 8, 2023 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (November 9, 2023) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 9, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 9, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.