197603952-10-29-2024-28-AS-TVAO-DAQN5D-20241105090919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 10/29/2024
Date Signed: 10/29/2024 01:24:59 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
10/11/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241011081106

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: 52	DATE:	10/29/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Lydia Pabion - Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility staff did not provide adequate supervision resulting in a resident eloping from the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Lydia Pabion and explained the reason of the visit.

The investigation consisted of the following: On 10/15/24 LPA conducted and initial complaint investigation visit. During the initial visit LPA requested staff/resident roster, resident #1(R1)’s physician’s report dated: 8/21/23, admission agreement, pre-appraisal, needs and care plan, medication sheet, incident report. LPA interviewed Resident #1-#3(R1-R3) and 5 staff. On 10/18/24 LPA interviewed R1’s Assisted Living Waiver (ALW) case manager over the phone and obtained documents. On 10/21/24 LPA interviewed R1’s Power of Attorney (POA) over the phone. On 10/29/24 LPA Flores delivered findings for the above allegation.

(CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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-20241011081106

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: 10/29/2024

NARRATIVE

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The investigation revealed the following: Regarding allegation: Facility staff did not provide adequate supervision resulting in a resident eloping from the facility. It is alleged a resident with dementia went missing for several hours. On 9/27/24 around 12:30pm R1 left the facility unattended with another resident. R1 did not return to the facility. Per administrator the facility’s policy is 24 hours to report the resident missing. Med-tech checked for R1 the morning of 9/28/24, R1 was not found. Med-tech contacted Pasadena police department to file a missing person report. A few hours later administrator was informed by Pasadena police department that they responded to a call for a person that seem to be confused around Del Mar and San Marino. Once the description was matched administrator and another staff went to pick up R1 around 11:00am from the area and returned R1 to the facility. No medical assessment was conducted. Interviews conducted with staff revealed R1 seems forgetful. However, staff believe R1 does not have dementia. Per staff, they know that R1 should not leave the facility unattended and when they see R1 in the lobby they redirect R1 to either R1’s room or dining room. LPA was unable to obtained information regarding the incident as R1 did not recall the incident. R2 who left the facility with R1 stated that when they were out R1 wanted to go for a walk, and they parted ways. Documents review revealed, two physician’s reports were obtained by LPA for R1; physician’s report dated: 8/21/23 notes R1’s has dementia and cannot leave the facility unattended. Physician’s report also dated: 8/21/23 obtained at the facility notes R1 has mild cognitive impairment and cannot leave the facility unattended. Medication sheet for September notes R1 is taking a medication prescribed for cognitive impairment. 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.

*Immediate $500 Civil penalties were assessed due to lack of care and supervision.*

Exit interview was conducted with Lydia Pabion and a copy of this report, LIC 9099D, 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: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20241011081106

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: 10/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/30/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, ... such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will obtain a physician's reassessment for R1, will assist R1 based on reassement, and will provide a copy to the department by POC due date 10/30/24.
	8 9 10 11 12 13 14	Based on documents review and interviews conducted licensee did not ensure R1 was properly assess or reasses based on changes in condition which poses an immediate health, safety, or personal right to the persons in care.	8 9 10 11 12 13 14	Immediate $500 Civil Penalties were assess
	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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC9099 (FAS) - (06/04)

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