<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 08/30/2025
Date Signed: 08/30/2025 11:24:46 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
05/23/2025 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250523163423
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: 49DATE:
08/30/2025
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Janice Somera - Med-TechTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not notify authorized representative of incident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*This report is a corrected version of report dated 8/5/25 to change finding and substantiated one of the allegations and add additional information.* Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Janice Somera and explained the reason for the visit.

The investigation consisted of the following: LPA requested staff/resident rosters. On 5/27/25 LPA Flores interviewed the administrator, 3 staff, 5 residents, reviewed file for resident #1-#2(R1-R2) and requested copies of medical assessment, needs and care plan, admission agreement, information and emergency information sheet, power of attorney, and incident reports. On 7/22/25, 7/28/25, and 7/31/25 LPA attempted to contact South Pasadena Police officer. On 7/31/25 LPA interviewed 1 staff over the phone. On 8/5/25 LPA delivered findings. On 8/7/25 LPA interviewed South Pasadena Police Department officer. On 8/11/25 LPA Flores interviewed R1's responsible party. On 8/29/25 LPA received a copy of police report.

(CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
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-20250523163423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PROSPECT MANOR
FACILITY NUMBER: 197603952
VISIT DATE: 08/30/2025
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
The investigation revealed the following: Regarding allegation: Facility staff did not notify authorized representative of incident. It is alleged facility staff did not notified R1’s responsible party regarding incidents that occurred on 5/7/25 and 6/11/25. Interviews with residents revealed facility staff notify their responsible party when necessary. Interviews with staff revealed Administrator or LVN are responsible for notifying responsible parties when incidents take place. Per administrator, on 5/8/25 administrator contacted R1’s responsible party via telephone at least three times and was unable to leave a voice message. Interview with R1’s responsible party revealed upon visiting R1 at the facility on 5/8/25, administrator stated to them that they had attempted to notify them of the bruise but had not been able to reach them. Regarding the incident on 6/11/25 responsible party called around 3:15pm and was asked to call police officer for details regarding an incident. Incident report dated 5/8/25 notes administrator notified responsible party. Incident report dated: 6/11/25 does not note responsible party was notified. Per police report reviewed, South Pasadena Police officer responded to a battery assault at the facility at 12: 32pm. Facility staff failed to notify R1’s responsible party of the incident that took place on 6/11/25 and requested to call police officer for details of the incident. Therefore, the allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted and a copy of this report, LIC 9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250523163423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PROSPECT MANOR
FACILITY NUMBER: 197603952
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
CCR
87211(a)(2)
1
2
3
4
5
6
7
87211 Reporting Requirements
(a) Each licensee shall furnish to the ...g: (2) Occurrences, ...outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents...
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will certify in writing that will ensure responsible parties are notify of any incidents and will update phone numbers, obtain other means to contact responsible party and submit a copy of certification to the department by POC due date 9/5/25.
8
9
10
11
12
13
14
Based on interviews and record review administrator failed to inform responsible party of incidents which poses a potential threat to the health, safety, or personal rights of the 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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
05/23/2025 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20250523163423

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: 49DATE:
08/30/2025
UNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Janice Somera - Med-TechTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide adequate supervision resulting in a resident being attacked by another resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*This report is a corrected version of report dated 8/5/25 to change finding and substantiated one of the allegations and add additional information.* Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Janice Somera and explained the reason for the visit.

The investigation consisted of the following: LPA requested staff/resident rosters. On 5/27/25 LPA Flores interviewed the administrator, 3 staff, 5 residents, reviewed file for resident #1-#2(R1-R2) and requested copies of medical assessment, needs and care plan, admission agreement, information and emergency information sheet, power of attorney, and incident reports. On 7/22/25, 7/28/25, and 7/31/25 LPA attempted to contact South Pasadena Police officer. On 7/31/25 LPA interviewed 1 staff over the phone. On 8/5/25 LPA delivered findings. On 8/7/25 LPA interviewed South Pasadena Police Department officer. On 8/11/25 LPA Flores interviewed R1's responsible party. On 8/29/25 LPA received a copy of police report.

(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250523163423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PROSPECT MANOR
FACILITY NUMBER: 197603952
VISIT DATE: 08/30/2025
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
The investigation revealed the following: Regarding allegation: Facility staff did not provide adequate supervision resulting in a resident being attacked by another resident. It is alleged that on 5/7/25, R1 was attacked by roommate resulting in an injury. Interviews conducted with residents revealed 4 out of 5 residents stated not have observed R2 having aggressive behaviors, hearing an argument, loud noises, or being hurt by R2 at the facility. 1 out of 5 residents stated R2 hit resident with an open hand in the face seven times the evening of 5/7/25. Interviews with staff determined staff did not observe or hear loud noises that indicate the incident was happening. Staff stated that on 5/8/25 LVN noted the bruise around the eye when providing eye drops in the morning. Per staff, R2 has not shown aggressive behavior in the last six months, other than the one incident they observed in the dining room on 6/11/25. Documents reviewed revealed; incident report dated 5/8/25 notes R1 was observed with a bruise in the eye and R1 stated that it was due to R2 hitting R1. R1 was provided with first aid assistance, and R2 was transferred to a different room. Incident report dated: 6/11/25 notes R2 was walking behind R1 in the dining room and pulled R1’s hair causing R1 to fall. The administrator contacted South Pasadena Police Department and police report was created. R2’s physician’s report does not note aggressive behaviors. Incident report review does not show a history of aggressive behavior’s observed of R2 in the last 2 years. Review of police report and video, it was observed that R2 drags R1 to the floor causing R1 to hit the side of the head against the rail and two staff respond to assist R1. Although R1 had a bruise on 5/8/25 it is unsure if R2 caused the bruise, and the incident on 6/11/25 did occur. However, The facility took action once the first incident happened and moved R2 to a different room. During the second incident Administrator contacted South Pasadena Police Department and sought care for R1 and R2. Therefore, the allegations is unsubstantiated.

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

Exit interview was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5