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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603952
Report Date: 10/10/2024
Date Signed: 10/10/2024 03:09:52 PM


Document Has Been Signed on 10/10/2024 03:09 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 MANORFACILITY NUMBER:
197603952
ADMINISTRATOR:LYDIA PABIONFACILITY TYPE:
740
ADDRESS:800 PROSPECT AVETELEPHONE:
(626) 799-1141
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY:99CENSUS: 50DATE:
10/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Lydia Pabion, AdministratorTIME COMPLETED:
03:23 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) Alberto Lopez made a subsequent visit to continue investigation and deliver findings for the for complaint 28-AS-20230922133247. LPA met with Staff Jose Deleon, and Administrator Lydia Pabion arrived a few minutes later and assisted with the visit.

During the investigation for the complaint mentioned above, the department discovered that facility had three (3) other deficiencies.

1) The facility failed to report to the department all the incidents the resident refused wound care to the department and other parties including resident's doctor.

2) The facility falsified records. S2 wrote in resident's record that wound care was provided on more than one occasion and both S1 and S2 both admitted to the department was not actually done.

3) Medical assessment was not in file for R1 prior to admission to facility.



Deficiencies cited on 809D, copy of report, 809D and appeal rights provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 10/10/2024 03:09 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: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2024
Section Cited
CCR
87211(a)(1)(d)

1
2
3
4
5
6
7
87211(a)(1) 87211 Reporting Requirements: (a) Each licensee shall furnish..: (1)A written report shall be submitted to the licensing agency... within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee will provide all the incident reports for the month of July, August and September 2023 for all the days the resident refused wound care. licensee will train all staff including administrator on reporting requirements and send signed log of staff attending, topic and name of trainer to LPA by POC date which is 10/17/2024
8
9
10
11
12
13
14
Facility did not report incidents when resident refused wound care during the months of July, August, and September, 2023
8
9
10
11
12
13
14
Type B
10/17/2024
Section Cited
CCR87458(a)

1
2
3
4
5
6
7
87458 Medical Assessment (a)(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The administrator will obtain and keep on file documentation of residents Medical Assessment or LIC602A signed by a physician prior to a person’s acceptance as a resident. The administrator will send LPA the future plan about obtaining medical assessment prior to accept resident by POC due date.
8
9
10
11
12
13
14
R1 LIC602 when admitted was not in resident's file and the LIC602A dated on 11/22/2022 was signed by medical doctor who stated he did not have R1 as patient.
8
9
10
11
12
13
14
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/10/2024 03:09 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: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2024
Section Cited
CCR
87207

1
2
3
4
5
6
7
False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This deficiency was evidenced by the following:
1
2
3
4
5
6
7
Licensee will document a statement indicating the understanding of the regulation and will confirm that all staff have been notified about consequences regarding false claims made to licensing staff.
8
9
10
11
12
13
14
During the course of a complaint investigation, Facility provided hand written documentation indicating that S2 had provided wound care to R1 on several occasions. Both S1 and S2 told the department that wound care was not provided.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3