197603952-12-5-2025-28-AS-WSHO-DQ6SJ8-20260109125444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 12/05/2025
Date Signed: 12/05/2025 11:12:38 AM

Unsubstantiated

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
07/28/2025 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250728111411

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: 47	DATE:	12/05/2025
		UNANNOUNCED	TIME BEGAN:	10:09 AM
MET WITH:	Jose De Leon - Maintenance Director		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not provided medical attention to resident as needed.
Staff did not follow resident’s care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Jose De Leon and explained the reason for the visit.

The investigation consisted of the following: On 8/5/25 LPA Flores conducted an initial complaint investigation visit, interviewed administrator and nurse and collected the following documents for Resident #1’s (R1) file and requested copies of physician’s report, needs and care plan, identification and emergency sheet, admission agreement, hospital discharge documents, medication sheets, and home health plan. On 8/28/25 LPA Flores conducted an unannounced subsequent complaint visit and interviewed 5 residents and 5 staff. On 9/18/25 LPA Flores contacted Home Health Agency. On 11/24/25 LPA Flores contacted R1 over the phone. On 12/5/25 LPA Flores delivered findings.

(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

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-20250728111411

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: 12/05/2025

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff did not provide medical attention to resident as needed. It is alleged R1 was in pain and medical assistance was not obtained. Interviews with 6 out of 6 residents stated facility staff assist them with obtaining medical care when needed. Interview with staff revealed 5 out of 5 staff stated that staff provide assistance to residents as soon as they require it. Per administrator and facility’s nurse, on 7/24/25 facility’s nurse provided pain medication to R1 once R1 complained of pain. Per facility’s nurse, R1 often has pain due to health-related conditions. Therefore, the plan is to provide pain medication as prescribed by physician. As soon as R1 continue to complain of pain, facility staff send the resident out to the hospital. Documents reviewed revealed, Home Health Visit notes dated 8/6/25, note R1 is to be provided Norco for pain as needed. Per July 2025 medication sheet, on 7/24/25 R1 was provided morning dose of Hydroco/APAP for pain, no additional doses were provided as R1 went out to the hospital.

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.

Regarding allegation: Staff did not follow resident’s care plan. It is alleged R1 required catheter care and facility staff did not provided. Interviews with residents revealed 6 out of 6 residents stated facility follows care plan or assist with care as needed. Interviews with staff revealed 5 out of 5 staff stated they follow resident’s care plan, which is explained by the administrator to the caregivers. Documents reviewed revealed Home Health Notes dated 7/23/25, note R1 was provided care for foley catheter by home health nurse and will continue to provide care and consult with physician regarding care. July 2025 medication sheet, notes R1 was being provided with antibiotics from 7/21/25-7/24/25. Home Health After Visit Summary notes R1 was at the hospital between 7/24/25-7/28/25 changes to antibiotics were noted. Although R1 had a change in condition, facility staff were following R1’s home health agency plan of care and a nurse was providing care with catheter. Therefore, this allegation 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 with Jose De Leon and a copy of this report was provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

LIC9099 (FAS) - (06/04)

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