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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 07/29/2021
Date Signed: 07/29/2021 02:08:11 PM



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
06/11/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20210611130511
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: 44DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Lydia Pabion - AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff allow residents to smoke inside the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation regarding the above allegations.

The investigation consisted of the following: On 6/16/21 LPA Flores interviewed administrator, conducted a tour of random rooms at the facility #223,222,209,211,206, 102,103,110,115,117,120,228,224,222, tested smoke detectors in rooms and hallways and observed designated smoking area per administrator approved by fire and police department. LPA interviewed residents #1(R1),#2(R2),#3(R3),#4(R4),#5(R5), and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5). On 6/17/21 LPA Flores contacted South Pasadena Fire Department (SPFD). On 7/29/21 LPA Flores contacted SPFD and clarify code for smoke detectors.

The investigation revealed the following: Regarding allegation: Staff allow residents to smoke inside the facility. It is alleged staff allow several residents on the second floor to smoke in their rooms. During facility's tour on 6/16/21 LPA observed resident in room #222 smoking in balcony and on 7/7/21 during a complaint investigation LPA observed resident in room #210 smoking inside the room. (CONTINUED LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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 6
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
06/11/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20210611130511

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: 44DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Lydia Pabion - AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility has bed bugs
Facility smoke alarms are inoperable
Resident's room door is obstructed
Facility elevator is in disrepair
Facility has cockroaches
Facility does not have a resident council
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation regarding the above allegations.

The investigation consisted of the following: On 6/16/21 LPA Flores interviewed administrator, conducted a tour of random rooms at the facility #223,222,209,211,206, 102,103,110,115,117,120,228,224,222, tested smoke detectors in rooms and hallways and observed designated smoking area per administrator approved by fire department. LPA interviewed residents #1(R1),#2(R2),#3(R3),#4(R4),#5(R5), and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5). On 6/17/21 LPA Flores contacted South Pasadena Fire Department (SPFD). On 7/29/21 LPA Flores contacted SPFD and clarify code for smoke detectors.

The investigation revealed the following: Regarding allegation: Facility has bed bugs and cockroaches. It is alleged facility has bed bugs and facility has cockroaches. During facility's tour LPA observed 14 residents rooms, including bed frames, bedding, and mattresses. Each bed, bedding, and mattresses were clean and no bed bugs were observed. Residents rooms, common areas, and kitchen were observed and no cockroaches were found. (CONTINUE LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20210611130511
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: 07/29/2021
NARRATIVE
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During interviews with residents, 4 out of 5 residents stated to not observed or have bed bugs or cockroaches at the facility. 1 out of 5 residents stated to have observed a cockroach in the bedroom's bathroom. During interviews with staff, 4 out of 5 staff stated to have not observed bed bugs or cockroaches in resident's rooms or facility. 1 out of 5 staff stated that resident brought a very small cockroach to her in a plastic bag but there are no other signs of pest at the facility. Facility has a pest control contract and services facility every two weeks. Facility was last served on 6/7/21.

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 UNSUBSTANTIATED.

Regarding allegation: Facility smoke alarms are inoperable. It is alleged the second floor does not have functioning smoke detectors. During facility's tour LPA observed 12 out of 14 bedrooms had a smoke detector in the bedrooms, all smoke detectors were tested and are in working order. 2 out of 14 bedrooms did not have a smog detector in the room. LPA observed a sprinkle fire system throughout the facility and sprinklers in each room. Maintenance staff stated the smoke detector in vacant room #228 was removed for remodeling and updating. On 7/29/21 LPA Flores contacted SPFD and spoke with Firefighter Rodriguez who stated per code it is not required for facility to have smoke detectors in each room only if facility has a sprinkle system which facility does.

Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found UNSUBSTANTIATED.

Regarding allegation: Resident's room door is obstructed. It is alleged room 211 is cluttered with random items that constantly block the resident's window and door. During facility's tour LPA observed room 211 does have many items in the floor and tables. Resident in room #211 has created about 4 feet path throughout the room to bathroom and door as well as floor room near bed and desk which allows resident usage of walker. Resident stated to be able to move around the room freely, does not want to get rid of items in his room, and has been assisted previously to dispose of some items. Administrator stated to have assisted resident in the past to get rid of some items and will continue to assist as resident brings new items. 3 out of 5 staff interview did not show concern in accessibility to the room to provide care or housekeeping. 2 out of 5 staff interview stated resident collects items but administrator assist with ensuring it does not block area.
(CONTINUED LIC 9099C)
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20210611130511
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: 07/29/2021
NARRATIVE
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Regarding allegation: Facility elevator is in disrepair. It is alleged elevator stopped working on 6/10/21 and residents are having trouble going up an down stairs. During facility's tour LPA observed elevator working properly. Administrator stated elevator was out for about an hour or less between the week of 6/6/21 to 6/11/21 once. Per administrator elevator door was not closing. Administrator called Performance Elevator Services who arrived within an hour removed an item that was preventing the door from closing, it was removed and no repairs were done by service company as there is no invoice regarding incident. Interviews with residents, 2 out of 5 residents stated elevator was out for a short time and 3 out of 5 residents do not use elevator or do not know if elevator was out. Interviews with staff, 3 out of 5 staff interview stated elevator was not working for less than an hour and 2 out of 5 staff stated to not know that elevator was not working. Resident roster shows residents in the second floor are ambulatory.

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 UNSUBSTANTIATED.

Regarding allegation: Facility does not have a resident council. It is alleged facility also does not have a resident council. During interviews with residents, 4 out of 5 residents stated facility has a resident council, 1 out of the 4 stated not to go because he does not hear the announcement in the intercom when they are announced. 1 out of 5 residents stated not to know if there is a council meeting as resident has been out in doctor's appointments and does not know if it is held or not. Interviews with staff, 5 out of 5 staff stated facility has a council meeting once a month and staff announces the meeting over intercom before it begins to allow residents to join. LPA reviewed copies of resident council meetings signing sheet and notes held on 4/16/21, 5/19/21, and 6/9/21.

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 UNSUBSTANTIATED.

Exit interview was conducted with Lydia Pabion administrator and a copy of report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20210611130511
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: 07/29/2021
NARRATIVE
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During interviews with 3 out 5 residents stated residents are not allowed to smoke in the facility and there is a smoking area in the back of the building. 1 out of 5 residents stated not to know if other residents were smoking outside, and 1 out of 5 residents stated residents are smoking in rooms. Interviews with staff, 3 out of 5 staff interview stated residents do not smoke in the rooms and 2 out of 4 staff stated residents smoke in balcony or residents must be reminded of no smoking in room policy. Facility's house rules state that residents should not smoke in rooms. Administrator stated house rules will be updated to reflect no smoking in facility or balconies which was previously discuss between administrator and licensee. Facility has zero residents under hospice and 2 residents in room 107 and 115 are under oxygen care per doctor's request.

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

Exit interview was conducted with Lydia Pabion administrator and a copy of this report LIC 9099D, and appeal rights was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20210611130511
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: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2021
Section Cited
CCR
87618(b)(3)(C)
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87618 Oxygen Administration-Gas and Liquid:(b)... the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (C)Smoking shall be prohibited where oxygen is in use.

This requirement is not met as evidency by:
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Administrator will ensure that residents at the facility are not smoking in bedrooms by certifying in LIC 9098 by 7/30/21 and will update and notify each resident by providing a copy of udated house rules: regarding house rules, smoking in rooms, smoking in the facility, and consequences of smoking in rooms by 8/4/21.
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Based on observation and interviews conducted residents in room 210, and 222 were observed smoking in rooms/balcony which poses an immediate health, safety, or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6