197603952-10-10-2024-28-AS-LHIS-DA2T7A-20241014142821

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 10/10/2024
Date Signed: 10/10/2024 03:08:07 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
09/22/2023 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230922133247

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:	10/10/2024
		UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	Lydia Pabion, Administrator		TIME COMPLETED:	03:23 PM

ALLEGATION(S):

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Staff neglected resident's wound in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez made a subsequent visit to continue investigation and deliver findings for the above mentioned allegation. LPA met with Administrator Lydia Pabion and discussed purpose of visit.

LPA interviewed Five (5) residents and one (1) additional staff S#1 during this visit. LPA took tour of facility and did not observed any health and safety Hazards.

On 09/25/2023; LPA conducted a health and safety check and took a tour of the physical plant including the common areas, kitchen, dining room, medications room, and five (5) resident rooms. LPA measured the water temperature, and it was within 105-120 degrees F. LPA observed that there was at least a 7-day supply of non-perishable foods, and a 2-day supply of perishable foods and medications were centrally stored and locked. The facility was clean and in good repair and there were no observable signs of neglect, abuse or other immediate health and safety threats. (Continue on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230922133247

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: 10/10/2024

NARRATIVE

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The investigation consisted of LPA interviewing five (5) residents (R#2-R#6) , R1 was not available for LPA to interview.
LPA interviewed three (3) staff (S#1-S#3) and reviewed the following documents, staff roster, resident roster, and for three (3) specified residents: resident face sheet, MAR log for July, August September 2023, physician’s report, most recent incident report and appraisal needs & services, Noyan Home Health records, facility progress notes, R1 hospital records. R1 LIC602A for R1 dated 01/19/2022, 11/02/22, and 04/12/2023

The investigation revealed: Regarding Allegation: Staff neglected resident's wound in care
LPA interviewed three (3) staff and three of three (3) staff denied the allegation. LPA interviewed five (5) residents and five (5) of (5) residents could not corroborate the allegation.

According to records reviewed and obtained, R1 was admitted to facility on 01/17/2022 and at that time, records show that R1 had skin intact without any open wounds. According to medical records, R1 wound care was ordered by Medical Doctor on 06/15/2023. Review of Home Health records show that R1 had developed a stage 4 wound by 06/30/2023. Department review of Noyan Home Health records indicate that resident refused wound care on the following days: 07/01,02,03,04,06,07,08,09,13,15,16,18,20,22,23,27,29,30th. According to records reviewed, R1 also refused wound care for days in August and September 2023. S2 stated she discussed R1 refusal of wound care with Administrator S1 and mentioned to Administrator S1 that resident required higher level of care. Both S1 and S2 admitted to the department that R1 refused wound care while at the facility. S1 admitted to the department that the facility is no longer able to meet R1 needs due to his high-risk behavior that causes safety concerns and R1 requires a higher level of care elsewhere. Under the admission agreement, the facility should have notified R1 physician and/or other appropriate persons regarding his change in condition and refusal of wound care treatment. R1 basic services under the facility admission agreement were not met. R1 actions could have possibly met the criteria for eviction under the admission agreement, but the administrator, S1, chose not to do anything about it and continued to house R1 at the facility, making him a risk to himself and others.
By retaining R1 at facility, facility neglected R1 wound care.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. The facility has been informed that Immediate civil penalty is being issued during today’s visit in the amount of $500.00, based on health and safety code 1569.49.
“The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). “

Exit interview was conducted with Lydia Pabion, Administrator and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230922133247

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: 10/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/11/2024 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities (a)...: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will certify in writing that staff including administrator will follow up on any medical need(s) of residents who refuse care and upon observation, communication, or discovery of such and will provide training to staff on the above and submit training logs to the department by POC due date of 10/11/2024.
	8 9 10 11 12 13 14	Based on department interviews conducted and documents reviewed licensee failed to ensure R1 did not develop a wound and neglected wound care by retaining R1 with stage 4 wound which poses an immediate risk to the health, safety, or personal rights to the persons in care. Immediate Civil Penalty for $500 is being issue	8 9 10 11 12 13 14
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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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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