197603952-2-15-2024-28-AS-MGFS-D2GUWU-20240215145719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603952
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:57:35 PM

Document Has Been Signed on 02/15/2024 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 50	DATE:	02/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Lydia Pabion - Administrator		TIME COMPLETED:	03:15 PM

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	Licensing Program Analyst(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with and explained the reason for the visit. Facility is licensed to served 99 adults over the age of 60 years old, of which 35 may be non-ambulatory. Facility has a hospice waiver for 4 and the following rooms are cleared for bedridden residents; 102 thru 110, 115 thru 119, and 123. Facility is a two story building with a commercial kitchen, a dining room, an activity room, a courtyard, a medication room, and front porch. No large bodies of water were observed. Sprinkler fire system throughout the facility. Fire extinguishers in hallways in each floor. LPA conducted a tour of the facility and observed the following: Activity area is clean, fireplace is inaccessible to residents. Dining room was observed in good repair and clean. Kitchen was observed clean, storage of food supplies was observed with sufficient perishables for at least 2 days, and non-perishables for 7 days. Kitchen wall behind the stove, was observed caved into the kitchen and with a gap between the floor and the wall the length of more than half the size of the wall and the width of about 3 inches. LPA observed 5 random resident rooms and observed sufficient lighting, furniture, and bedding supplies. Each room has a bathroom and were observed in working condition, with grab bars, and skid mats. Water temperature was tested between 110.6 - 138.3 degrees F. which is not within the required 105-120 degrees F. Shower faucet in room #207 was observed cracked and missing half of the faucet. Ramps, and stairways were observed clear of obstructions. Stairways are missing an evacuation chair. Courtyard provides shaded sitting area, front porch provides sitting area, and back area provides a smoking area. Carbon monoxide/Smoke detectors were tested and are in working condition. Facility stores additional linens, and cleaning supplies were observed in a closet. Sharps are stored in the kitchen and residents do not have access to the kitchen. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/15/2024

NARRATIVE

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LPA reviewed medications for 5 residents, resident #2(R2) was out of prescribed medication filled on 1/25/24 and LVN stated to have been giving R2 additional pills due to R2 requesting it. Per prescription R2 is to have 2 pills per day, LVN has been providing more per day.
LPA reviewed 5 resident and 5 staff files. Emergency Disaster plan and Infection control plans were reviewed last reviewed/updated in 2022.
A copy of Liability Insurance was provided. Administrator certificate was observed for Lydia Pabion #6006152740 exp: 8/10/25.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Lydia Pabion and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 02/15/2024 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in water temperature tested in room #122 tested at 122.0 degrees F., room #118 tested at 130.6 degrees F., room #223 tested at 138.3 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	Maintenance will adjust water heater and administrator will certify in writing that water temperature will be maintain within the required 105-120 degrees F. in writing by POC 2/16/24, and will submit a temperature log maintain for the rooms above for the following 7 days and will submit the temperature log by 2/23/24.

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in R2's medication filled on 1/25/24 was out and LVN stated to have provided R2 additional pills to the dosage prescribed by the physician which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	Administrator will schedule training for LVN with a pharmacist which will cover providing medication to persons in care and the side effects of providing medication outside of the prescribed dosage, will notifiy the department of date of training by POC date 2/16/24 and will submit training certificate to the department by 2/29/24. Administrator will have R2 evaluated for correct prescription.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2024 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

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 evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in kitchen wall by stove was observed caved into the kitchen leaving a gap between the floor and the wall of about 3 in x 4 ft in, shower faucet in room 207 was cracked and half way gone which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/26/2024
	Plan of Correction
1 2 3 4	Administrator will ensure repairs are done in the kitchen wall and replace the faucet and will submit a picture of repairs to the department by POC 2/26/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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