197603952-8-29-2022-28-AS-RORN-CJPPM4-20220928112544

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 08/29/2022
Date Signed: 08/29/2022 03:13:47 PM

Unsubstantiated

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
08/22/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220822155527

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: 54	DATE:	08/29/2022
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Lydia Pabion - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff member mismanages residents’ medication
Staff failed to meet residents' needs

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 met with Lydia Pabion Administrator and explained the reason for the visit.

The investigation consisted of the following: LPA Flores requested a copy of the staff/resident roster. LPA Flores reviewed medication for Resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6) and interviewed R1,R2,R3,R4R5,R6, staff #1(S1),#2(S2),#3(S3),#4(S4). LPA toured the facility and observed rooms #107,108,118,212, and 219. LPA Flores requested copies of medication sheets for June, July, August, medication delivery invoices, physician's reports, admission agreement, identification and appraisal/needs and care plan.

(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

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-20220822155527

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: 08/29/2022

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff member mismanages residents' medication. It is alleged staff administers the residents’ medication too early and it conflicts with the residents’ last medication doses. Interviews with residents revealed 3 out of 6 residents interviewed stated to be receiving medication at the times provided and that it does not interfere with their other doses. 1 out of 6 residents stated to not take medication. 1 out of 6 residents was unable to be interview due to cognitive skills and 1 out of 6 residents refused to be interview. Interviews with staff revealed 4 out of 4 staff stated medication is provided to the residents for each dose according to the prescription. Administrator stated that morning dose is provided to residents between 7:30am - 8:00am, Noon dose is provided between 11:30am - 12:00pm, Evening dose is provided between 4:30pm - 5:00pm and Bedtime dose is provided between 7:30pm - 8:00pm. LPA Flores reviewed medication sheets for R1,R2,R3,R4,R5,R6 did not observed any medication listed that will interfere with other medication provide to the residents based on the doses or times. Facility last provided medication training to S3 and S4 on 8/21/22 and S2 vocational nurse license expires on 11/30/22.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Regarding allegation: Staff failed to meet residents' needs. It is alleged the facility doesn’t provide masks to residents/staff members and doesn’t enforce masks at the facility. Interviews with residents revealed 4 out of 6 residents stated staff wear a face mask at the facility and provide a face mask when needed and facility is meeting their needs. 1 out of 6 residents was unable to be interview due to cognitive skills and 1 out of 6 residents refused to be interviewed. Interviews with staff revealed 3 out of 4 staff stated facility provides face mask for staff and residents and 1 out of 4 staff stated not to be sure if facility continues to provide face mask for staff or residents. LPA Flores observed administrator maintains mask at the facility, staff were observed wearing a face mask during the tour of the facility. No further details were provided in the complaint description regarding the needs of the residents not being met.

Based on interviews conducted and observations made, there was insufficient evidence to prove the allegation(s).Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview was conducted with Lydia Pabion - Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

LIC9099 (FAS) - (06/04)

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