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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 06/13/2022
Date Signed: 06/13/2022 01:20:30 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
01/04/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220104152734
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: 51DATE:
06/13/2022
UNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Lydia Pabion - Administrator TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility elevator is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit 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: On 1/11/22 LPA Flores requested facilities resident and staff roster conducted a tour of the facility with Lydia Pabion, observed and used elevator to access 2nd floor, tour room #209, 216,219, 224. Interview residents #1(R1), #2(R2), #3(R3), #4(R4) and obtained copies of facility's fire disaster evacuation plan, and activities January 2022 schedule. On 6/13/22 LPA Flores requested staff/resident roster, interviewed resident #5(R5),#6(R6) and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5) and obtained copies of physician's report, emergency and identification information sheet and medication sheets for December 2021, January, February, and May 2022 for 6 residents interviewed.

(CONTINUED LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
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
Control Number 28-AS-20220104152734
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: 06/13/2022
NARRATIVE
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The investigation revealed the following: Regarding allegation: Facility elevator is in disrepair. It is alleged the elevator is broken and has been for about a month. Interviews with residents revealed 3 out of 6 residents interview stated elevator is not working and residents have to use stairs causing some physical discomfort. 2 out of 6 residents interview stated not to use elevator as they reside in the first floor and 1 out of 6 residents refused to be interviewed. 5 out of 5 staff interviewed stated elevator was out of service in January and residents were assisted in stairway. On 1/11/22 Licensee stated a part on the board of the elevator had to be special order as the part is no longer produced by the company which delayed the repaired of the elevator. During the visit on 1/11/22 LPA Flores used the elevator to go to the second floor. LPA review service repairs invoice #41646 dated 12/27/21 notes "Returned Elevator to Service Ticket # 39334 12/02/21" and invoice #41647 dated 12/27/21 notes "Returned to service and ran as intended Ticket # 39359 12/09/21".

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.

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

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
01/04/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220104152734

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: 51DATE:
06/13/2022
UNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Lydia Pabion - Administrator TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Residents are not being provided activities.
Medications are not being administered to residents properly.
Residents do not have a safe escape route in case of a fire.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit 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: On 1/11/22 LPA Flores requested facilities resident and staff roster conducted a tour of the facility with Lydia Pabion, observed and used elevator to access 2nd floor, tour room #209, 216,219, 224. Interview residents #1(R1), #2(R2), #3(R3), #4(R4), and obtained copies of facility's fire disaster evacuation plan, and activities January 2022 schedule. On 6/13/22 LPA Flores requested staff/resident roster, interviewed resident #5(R5),#6(R6) and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5) and obtained copies of physician's report, emergency and identification information sheet and medication sheets for December 2021, January, February, and May 2022 for 6 residents interviewed.

(CONTINUED LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20220104152734
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: 06/13/2022
NARRATIVE
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The investigation revealed the following: Regarding allegation: Residents are not being provided activities. It is alleged that due to the elevator not working, residents on the second floor are not able to come downstairs and engage in exercise and social activities. Interviews with residents revealed 3 out of 6 residents interview stated not to join activities provided by personal choice. 1 out of 6 residents interview stated residents in second floor are not able to join activities as "it is hard to come down" stairs. 1 out of 6 residents interview stated to join activities and receive assistance coming down stairs if needed. 1 out of 6 residents interview refused to be interviewed. Interviews with staff revealed, 5 out of 5 staff stated that residents were assisted to come down stairs to participate in activities. Documents reviewed revealed activity schedule for January 2022 list activities provided daily for residents in care and 4 out of 6 residents residing in the second floor are noted as ambulatory in physician's report.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Regarding allegation: Medications are not being administered to residents properly. It is alleged the elevator is use to bring medication carts with resident's medications, but now that elevator is not working results in staff not being able to fill the medication cup in front of the residents. Interviews with residents revealed 3 out of 6 residents stated to have received their medication during the time the elevator was out of service. 2 out of 6 residents do not take medication and 1 out of 6 residents refused to be interview. 5 out of 5 staff stated medications were being provided to residents in their room and previously preparing dose in the medication room, placing medication from bubble pack or container into a label cup with residents name and room number and carried in a tray instead of medication cart along with water to residents in second floor. Medication sheets reviewed revealed 4 out of 6 residents received medications during the time elevator was out of service.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Regarding allegation: Residents do not have a safe escape route in case of a fire. It is alleged if a fire were to happen at this facility many of the residents on the second floor who are wheelchair bound, or use walkers would be trapped because they would not be able to take the stairs to escape due to elevator not working. Interviews with residents revealed 3 out 6 residents interview stated to be able to use the stairs,
(CONTINUED LIC 9099C)
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20220104152734
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: 06/13/2022
NARRATIVE
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residents have physical discomfort but are not restrained from using stairs. 2 out of 6 residents interview do not use stairs as they reside in the first floor and 1 out of 6 residents refused to be interviewed. Staff interviews revealed 5 out of 5 staff stated that residents in the second floor are ambulatory but may use walker for support and when they use stairs staff provide assistance to ensure their safety. Documents reviewed revealed Fire Drill Report dated 12/3/21 was conducted at 1:00pm and on 2/25/22 at 1:40pm. Fire & Life Safety Inspection Form from City of South Pasadena Fire Department dated 9/2/21 notes that exit doors, aisles and stairways are free of obstruction and all exit doors are unlocked. Emergency and Disaster Plan for Residential Care Facilities for the Elderly was reviewed and updated on 11/2/21 and on 6/1/22. Physician's Reports reviewed revealed R1,R2,R3,R4 residing in second floor are ambulatory.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

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

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20220104152734
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: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2022
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 provided elevator repaired order dated 1/19/22 during this visit. Deficiency has been cleared as of 6/13/22.
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Based on interviews and documents reviewed licensee did not ensure elevator was in working conditions at all times wich poses a potential health, safety, or personal rights risk for residents 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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6