197603952-5-6-2021-28-AS-MVAO-C5BM39-20210727091446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 05/06/2021
Date Signed: 05/06/2021 04:15:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/08/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210108120250

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: 36	DATE:	05/06/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Lydia Pabion		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not properly report incidents involving residents while in care
Staff did not have planned activities for residents
Staff not able to assist residents with dementia

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Lydia Pabion, the facility administrator.

During the course of the investigation, LPA Spencer took a physical plant tour and conducted telephone interviewed administrator Lydia Pabion, staff #1-5 (S1-S5), and resident #1-3 (R1-R3). R3 is currently at rehabilitation center and S3 is no longer working there so these individuals could not be interviewed. The LPA reviewed copies of Staff Roster, Resident roster, Activities calendar for January 2021, and In-service training logs. For R1-R3, LPA reviewed the Needs & Services Plan and Physician's Reports and Incident reports.
***Narrative continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/08/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210108120250

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: 36	DATE:	05/06/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Lydia Pabion		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Residents did not receive personal mail
Staff did not prevent residents from wandering

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20210108120250

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PROSPECT MANOR	FACILITY NUMBER: 197603952
	VISIT DATE: 05/06/2021

NARRATIVE

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The investigation revealed the following:

Residents did not receive personal mail
It was alleged that resident's mail was backed up and staff were not distributing mail to residents in a timely manner. During the observation, LPA did not observe undistributed mail. When interviewed, the administrator stated that usually residents get their mail daily but admitted that, during the pandemic, mail had not been distributed in a timely manner. She stated that there was no designated person assigned to distribute it and that all staff are responsible. S1 and S2 stated that residents get their mail daily and they assist with sorting out the mail. S4 stated that when she came back from being on leave in December 2020, she noticed a large amount of undistributed mail in boxes and that she was tasked to distribute it when she returned. S5 stated that before pandemic, residents were getting their mail daily, but during the pandemic he was unsure if it was being distributed daily. S1 and S4 said that some residents have complained about not getting their mail. R1 stated that he receives his mail everyday or every other day.
Staff did not prevent residents from wandering
The administrator acknowledged that R1 had a history of wandering away from the facility but stated that he no longer lives at the facility. She stated that the resident liked to wander and she assigned staff to walk him three times a day. However, she stated that when she was out sick in December, no staff knew to take him for walks which led to him wandering alone. S1 stated that due to R1's history of wandering, they began doing 1 on 1 supervision after the incident on 12/26/20 where police found him in the community at 2 a.m. S1 also stated that on 12/27/20, an in-service training was completed for all staff and the 2 staff on-duty that night were terminated. S2 and S4 also confirmed R1's tendency to wander while S5 was not aware of residents wandering. R1 and R2 did not recall any instances of wandering away from the facility. A review of incident reports for R1 reveals that he wandered on 12/26/20 and again on 12/29/20. On 1/17/21, family members decided to move him out of the facility. R1's physician's report state that the resident has mild cognitive, visual, and motor impairment. The Needs and Services plan states that staff should assist him with taking walks daily.

Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. CCR Title 22, Division 6, Chapter 8 is being cited on attached LIC9099D. An exit interview was conducted and copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210108120250

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PROSPECT MANOR	FACILITY NUMBER: 197603952
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/07/2021 Section Cited CCR 87461(a)(1)	1 2 3 4 5 6 7	87461(a)(1) Mental Condition: 87461(a)(1): The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual:(1) tends to wander. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The administrator stated that R1 no longer lives at the facility. The administrator will ensure that residents are annually assessed and that wanderers receive one to one assistance when walking or leaving the facility. The adminstrator will self-certify that the facility will keep a list of residents who wander and implement a walking plan in their care plan and submit to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interviews and records reviews, the licensee did not ensure that R1 was supervised and accompanied when leaving the facility on two occasions on 12/26/20 and 12/29/20. This poses an immediate safety risk to persons in care.	8 9 10 11 12 13 14
Type B 05/07/2021 Section Cited CCR 87468.1(a)(15)	1 2 3 4 5 6 7	87468.1(a)(15) Personal Rights of Residents in all facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The administrator stated that she will assign a lead and a back-up lead in charge of sorting and distributing the mail daily. The administrator will create a mail distribution log that is checked off daily and send CCL a copy by POC due date.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not ensure that residents received their mail in a prompt manner daily. This poses a potential risk to personal rights of persons in care.	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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20210108120250

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PROSPECT MANOR	FACILITY NUMBER: 197603952
	VISIT DATE: 05/06/2021

NARRATIVE

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The investigation revealed the following:

Staff did not properly report incidents involving residents while in care
LPA Spencer reviewed all incident reports for R1-R3 from December 2020-January 2021. Incident reports were received regarding R1's unauthorized absences from the facility on 12/26/21 and 12/29/21, R2's fall on 1/5/21, and R3's hospitalization on 1/3/21. In an interview, R2 stated that he has had falls at the facility but nothing serious and staff assisted him each time. Upon review of the dates of the incident reports, all incident reports were sent within 7 days of occurrence. In interviews, staff stated that they report all incidences to the administrator and the administrator or lead staff send the incident reports to licensing within 7 days. The administrator and S1 stated that they send incident reports and have trained the lead staff on sending incident reports when they are not at the facility.
Staff did not have planned activities for residents
Staff were interviewed and all stated that during COVID-19 pandemic, there were no communal planned activities. The administrator stated that the activities director was out sick in December and there were no planned group activities during this time. However, S1 stated that there were individual activities provided for residents in their room. She stated that now that quarantine is over for most residents, they have resumed group planned activities for residents. S2 stated that there are planned activities such as prayer, exercise, outings to the store, art, and movie nights. He stated that during quarantine, residents were provided individual activities such as activity books, word searches, and drawing. LPA reviewed the Activities Calendar from January 2021 and it revealed a variety of planned activities. LPA also reviewed the training log showing that staff were trained on helping residents with mental/physical stimulation during COVID-19. R1 and R2 interviewed and stated that there are a variety of activities including music, dancing, and games.
Staff not able to assist residents with dementia
LPA Spencer reviewed the Physician's reports and Needs & Services plan for R1-R3 and none were listed as having dementia but R1 and R3 have mild cognitive impairment. The administrator and staff stated that there are no residents with formal diagnosis of dementia. S1, S2, and S5 said that they have received training on caring for residents with dementia. R1 and R2 stated that they were unaware of any residents having dementia.
Based upon interviews and records reviewed, the findings indicate that although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated. A telephonic exit interview was conducted, a copy of the report was emailed, and staff was instructed to sign and return to LPA.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

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