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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 02/08/2021
Date Signed: 02/08/2021 04:35:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/03/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20210203140838
FACILITY NAME:PROSPECT MANORFACILITY NUMBER:
197603952
ADMINISTRATOR:LYDIA PABIONFACILITY TYPE:
740
ADDRESS:800 PROSPECT AVETELEPHONE:
(626) 799-1141
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY:99CENSUS: 41DATE:
02/08/2021
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Lydia Pabion - AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Lydia Pabion, the facility administrator.

LPA Flores conducted telephone interviews with the administrator (S1), residents #1,#2,#3, and #4 (R1,R2,R3,R4), staff #2,#3, and #4 (S2,S3,S4) and a video call which consisted of a review of bedrooms #231, 230, 232, 123,122,119,120,117, 118. The LPA also requested copies of staff and resident roster, resident's physician's report, resident's admission agreement, Pest Control Invoice, Facility's sketch to be emailed to the LPA’s email address. LPA Flores reviewed Incident Report faxed to the department on 1/15/21.

The investigation revealed the following: Regarding allegation; Facility has bed bugs; It is alleged facility is experiencing a bed bug infestation. During the facility tour LPA did not observed any stains, or bugs in the mattress, mattress board, or bed frame of rooms observed.
(Continued 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20210203140838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PROSPECT MANOR
FACILITY NUMBER: 197603952
VISIT DATE: 02/08/2021
NARRATIVE
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LPA also was informed and observed that room #231 had a new bed frame and mattress board. During interviews 3 out of 4 residents stated to not observed any insects or bed bugs in the facility, as well as to receive any insect bites. 1 out of 4 residents was unable to answer and During interviews 2 out of 4 staff stayed that a room in the facility was treated for bed bugs and 2 out 2 staff stayed to not observed any bed bugs or insects in the facility . LPA Flores reviewed facility's incident report faxed to the department on 1/15/21 and dated 1/14/21, in which the facility stated the following "it was confirmed they are bed bugs." Interview with administrator explained that the facility had bed bug treatment in room #231 and family members changed resident's bed.

Based on LPA's observations, interviews, and document review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found Substantiated. California of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.


A telephonic exit interview was conducted with Lydia Pabion, and a hard copy was provided via email for signature.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210203140838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PROSPECT MANOR
FACILITY NUMBER: 197603952
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/08/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation; (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidence by:
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Licensee will ensure that the facilty is free of bed bugs at all times. POC has been clear and no further action is necessary at this time.
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Based on observation, interviews, and documents reviewed licensee did not ensure to keep facility free of bed bugs. LPA Flores reviewed Incident report self reported confirming bed bugs at facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3