197603952-7-7-2021-28-AS-MVAO-CAMPYZ-20220113104443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 07/07/2021
Date Signed: 07/07/2021 04:36:52 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
06/28/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210628101748

FACILITY NAME:	PROSPECT MANOR		FACILITY NUMBER:	197603952
ADMINISTRATOR:	LYDIA PABION		FACILITY TYPE:	740
ADDRESS:	800 PROSPECT AVE		TELEPHONE:	(626) 799-1141
CITY:	SOUTH PASADENA	STATE: CA	ZIP CODE:	91030
CAPACITY:	99	CENSUS: 45	DATE:	07/07/2021
		UNANNOUNCED	TIME BEGAN:	01:03 PM
MET WITH:	Lydia Pabion - Administrator		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation regarding the above allegation(s). LPA Flores met with Lydia Pabion administrator and explained the reason for the visit.

The investigation consisted of the following: LPA Flores conducted a tour of the facility at around 1:15pm which consisted of the common areas, kitchen, and random pick rooms #227, 210, 110, 107, 105 water temperature was tested in each room and tested between 77.6 to 114.5 degrees F which is not between the required 105 - 120 degrees F. LPA interviewed administrator and resident #1 (R1), and requested the following documents; Admission agreement, physician's report, medication sheet for June, any incident reports, face sheet for R1, resident #2(R2), #3(R3), #4(R4), #5(R5) and job description for staff #1 (S1), #2(S2), #3(S3), #4(S4), and staff and resident roster.

The investigation reveled the following: Regarding allegation; Facility is in disrepair. It is alleged patio door is broken, has told several times to the facility and nothing has been done. (CONTINUED LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210628101748

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: 07/07/2021

NARRATIVE

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During the facility's tour LPA observed a plastic covered holed in the dinning room's ceiling due to a leak, kitchen's refrigerator temperature at 45.2 degrees F and freezer temperature at 20.0 degrees F, second floor left hallway middle window crack on left bottom corner and right hallway middle window screen ripped on bottom left corner, room #210 water temperature read at 96.1 degrees F, and balcony screen door was off rails leaning against window, room# 105's ceiling had 3 patches large about a foot long of peel paint and sink's water drain is rusted around, and room #107 water temperature was read at 99.4 degrees F.

Based on LPA's observations, 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 and a copy of the report, LIC 9099D, and appeal rights was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20210628101748

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: 07/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/08/2021 Section Cited CCR 87555(b)(21)	1 2 3 4 5 6 7	87555 General Food Service Requeriments: (a) The following food service requirements shall apply: (21) Freezers... shall be maintained at a temperature of 0 degrees F ..., and refrigerators... shall maintain a maximum temperature of 40 degrees F .... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will certify on LIC 9098 and ensure to maintain proper refrigerator and freezer temperature. Administrator contacted refrigerator maintenance company, will have schedule refrigerator repair, and submit LIC9098 by 7/8/21.
	8 9 10 11 12 13 14	Based on LPA observation, administrator did not ensure refrigerator and freezer temperature were under the require temperature as observed freezer at 20 degrees, and refrigerator at 45.2 degrees which poses an immediate health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 07/21/2021 Section Cited CCR 87303(e)(2)	1 2 3 4 5 6 7	87303 Maintenance and Operation: (e)Water supplies and plumbing fixtures shall be maintained as follows: (2).... Hot water temperature controls shall be maintained to automatically regulate.. temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will ensure water temperature is maintain within the required range of 105-120 degrees F at all times. Administrator will certify with LIC 9098 and maintain a water temperature log that will be submitted to the department by 7/21/21.
	8 9 10 11 12 13 14	Based on observation facility failed to maintain water temperature within the required 105-120 temperature as read in rooms #105 at 77.6 degrees F, #107 at 99.4 degrees F and, #210 at 96.1 degrees F which poses a potential health, safety, or personal rights risk to person in care.	8 9 10 11 12 13 14

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 Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 28-AS-20210628101748

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: 07/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/21/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Administrator will schedule repairs of room #105, room #210 and windows in second floor and will submit a picture of the repairs to the department by 7/21/21.
	8 9 10 11 12 13 14	Based on observation facility did not ensure facility is in good repair as room #210 has a balcony screen door off rails, #105 ceiling is peeling in three areas, 1 middle window in 2nd floor hallway crack and 1 window screen ripped and leak in dinning room which poses a potential health, safety, or personal risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

LIC9099 (FAS) - (06/04)

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