197603952-1-9-2024-28-AS-RORN-CZJMGJ-20240116083601

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:50:40 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
10/30/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231030095916

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: 52	DATE:	01/09/2024
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Lydia Pabion - Administrator		TIME COMPLETED:	03:04 PM

ALLEGATION(S):

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Staff is sleeping at the facility.

INVESTIGATION FINDINGS:

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13

*This report supersedes report dated 11/07/2023 due to findings changed for 1 allegation*
Licensing Program Analysts (LPAs) Mora and Vaid conducted an unannounced complaint visit regarding the above allegations. LPAs met with Lydia Pabion (Administrator) and explained the reason for the visit.

The investigation consisted of the following: LPAs obtained copies of staff and resident rosters, reviewed pest control reports dating back to June 2023, and interviewed Administrator, Staff 1 - Staff 6 (S1 - S6) and Resident 1 - Resident 7 (R1 - R7). LPAs also toured 3 resident rooms and the facility's TV room.

The investigation revealed the following: regarding the allegation "staff are sleeping at the facility", it is alleged that staff are sleeping at the facility during their shifts. Administrator stated 2 months ago she reviewed her camera footage and noticed a graveyard staff sleeping on job. She confronted the staff and the staff resigned on 09/14/23. Administrator stated this was a one time incident and no other staff have slept on the job. Staff interviewed could not corroborate the allegation. Residents interviewed could not corroborate the allegation. (Continued to LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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 5

Control Number 28-AS-20231030095916

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PROSPECT MANOR	FACILITY NUMBER: 197603952
	VISIT DATE: 01/09/2024

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on LPA's interviews, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
10/30/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231030095916

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: 52	DATE:	01/09/2024
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Lydia Pabion - Administrator		TIME COMPLETED:	03:04 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility has bedbugs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

***This report supersedes report dated 11/07/2023 due to findings changed for 1 allegation***
Licensing Program Analysts (LPAs) Mora and Vaid conducted an unannounced complaint visit regarding the above allegations. LPAs met with Lydia Pabion (Administrator) and explained the reason for the visit.

The investigation consisted of the following: LPAs obtained copies of staff and resident rosters, reviewed pest control reports dating back to June 2023, and interviewed Administrator, Staff 1 - Staff 6 (S1 - S6) and Resident 1 - Resident 7 (R1 - R7). LPAs also toured 3 resident rooms and the facility's TV room.

The investigation revealed the following: regarding the allegation "facility has bedbugs", it is alleged that there are bedbugs in rooms 201, 205, 227 and the facility's TV room. Administrator denied the allegation and stated no bedbugs complaints have been brought to her attention. Staff interviewed could not corroborate the allegations. Residents in rooms 201 and 227 denied having bedbugs and resident in room 205 was out in the community and not available for an interview. (Continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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 5

Control Number 28-AS-20231030095916

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PROSPECT MANOR	FACILITY NUMBER: 197603952
	VISIT DATE: 01/09/2024

NARRATIVE

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The other residents interviewed could not corroborate the allegation. During the tour, LPAs did not observed bedbugs in the facility's TV room nor in rooms 201 and 227. Room 205 was locked due to resident was out in the community. LPAs also reviewed pest control reports dating back to June 2023 and all reports stated no activity was noticed.

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 held and a copy of the report was provided

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20231030095916

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PROSPECT MANOR	FACILITY NUMBER: 197603952
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/16/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.....	1 2 3 4 5 6 7	Licensee is to comply with Title 22 Section 87411 at all times. Additionally, Licensee will conduct an in-service training with all staff and submit a training log with all staff signatures to Community Care Licensing Division (CCLD) by 01/16/2024.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. A staff was caught sleeping on the job.	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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5