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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 05/26/2021
Date Signed: 05/26/2021 10:30:43 AM



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 Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210108112826
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: 45DATE:
05/26/2021
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Lydia Pabion, AdministratorTIME COMPLETED:
10:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are mishandling residents’ medications
Staff are not properly feeding the residents while in care
Facility has inadequate record keeping
Staff failed to meet residents’ incontinence needs while in care
Staff did not provide laundry services to residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint investigation for the allegations listed above. LPA met with Lydia Pabion, administrator and explained the reason for the visit. The initial complaint visit was conducted on 1/19/21.

The investigation consisted of the following: On 1/19/21, interviews were conducted with 3 residents and 1 staff member. The facility was also virtually toured. On 4/26/21, administrator was interviewed. On 4/27/21, 6 additional staff were interviewed, and the former Temporary Manager was interviewed.

Allegation: Staff are mishandling residents’ medications. Resident #1’s (R1) Medication Administration Record (MAR) for December 2020 was reviewed. 8 of R1’s medications on the MAR were not initialed from 12/12/20 – 12/16/20. 1 medication was not initialed from 12/12/20 – 12/19/20. 1 other medication was not initialed from 12/13/20 – 12/16/20. One resident reported that they missed 12 days of their medications sometime in December 2020. Continued on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 28-AS-20210108112826
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: 05/26/2021
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
26
27
28
29
30
31
32
Another resident indicated that they didn’t have access to their PRN (as needed medication) in December 2020 because staff could not find it. Staff interviewed reported that prior to the TM2 arriving to the facility, the medications were not being handled properly. Medications were reportedly found on the floor or in wrong medication bottles. TM2 indicated that the prior Temporary Manager (TM1) admitted that some of the residents were not receiving their medications daily because there was insufficient staff. Based on interviews conducted and records reviewed, the allegation is substantiated.

Allegation: Staff are not properly feeding the residents while in care. 1 resident indicated that when TM1 was operating the facility the food was not good and many times staff were bringing food from outside. 3 staff interviewed confirmed the food was not of good quality when TM1 was operating the facility and staff confirmed that many times food was being brought from outside because facility did not have a cook. TM2 reported that she had to hire a cook when she began to operate the facility because TM1 did not have a full-time cook. Based on interviews conducted, the allegation is substantiated.

Allegation: Facility has inadequate record keeping. Staff interviewed confirmed that the records were disorganized when TM1 was operating the facility. LPA reviewed MARs and confirmed the medication records were not being completed as required. Based on interviews conducted and records reviewed, the allegation is substantiated.

Allegation: Staff failed to meet residents’ incontinence needs while in care. TM2 reported that the first day TM2 took over operation she had a nurse evaluate all the incontinent residents. There were many residents with redness possibly due to not being changed often. Other staff indicated that when TM1 was operating the facility there was insufficient staff to change all the residents and staff confirmed that they would find the residents really wet and their beds would be wet. Based on interviews conducted, the allegation is substantiated.

Allegation: Staff did not provide laundry services to residents. 1 of the resident’s interviewed indicated that there were no staff to do laundry when TM1 was operating the facility. 1 staff indicated that residents were complaining about their laundry not being done. Another staff indicated there was no one assigned to laundry when TM1 was operating the facility. The laundry didn’t get done until TM2 arrived. Based on the information obtained, the allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. The deficiencies are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20210108112826
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: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2021
Section Cited
CCR
87465(a)(5)
1
2
3
4
5
6
7
Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed.
1
2
3
4
5
6
7
As of 1/5/21 the administrator had returned full time. Staff and residents report that the facility is back to normal and all medications are being administered properly. Administrator will certify all medications are being administered properly.
8
9
10
11
12
13
14
This deficiency was evidenced by the following: Interviews conducted with staff and residents confirmed medication were not being given as prescribed. The resident’s MAR was also not being completed properly.
8
9
10
11
12
13
14
Type A
05/28/2021
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
1
2
3
4
5
6
7
As of 1/5/21 the administrator had returned full time Staff and residents report that the facility is back to normal staff ratios. Interviews indicated this was an issue when TM1 was operating the facility. Administrator will certify all residents needs will be met.
8
9
10
11
12
13
14
This deficiency was evidenced by the following: TM2 reported that incontinent residents were assessed and many had redness consistent with not being changed often. Other staff indicated that when TM1 was operating the facility there was insufficient staff to change residents and staff would find residents wet.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20210108112826
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: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2021
Section Cited
CCR
87555(b)(18)
1
2
3
4
5
6
7
General Food Service Requirements
(b) The following food service requirements shall apply:
(18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents.
1
2
3
4
5
6
7
As of 1/5/21 the administrator had returned full time. Administrator indicated the regular cook returned after being gone when TM1 was operating the facility. Administrator will certify that the regular cook has returned.
8
9
10
11
12
13
14
This deficiency was evidenced by the following: Interviews conducted with staff and residents confirmed the facility food was not of good quality when TM1 was operating and many times food was brought in from outside because there was no cook.
8
9
10
11
12
13
14
Type B
05/28/2021
Section Cited
CCR
87506(a)
1
2
3
4
5
6
7
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
1
2
3
4
5
6
7
As of 1/5/21 the administrator had returned full time. Staff interviewed indicated the records are back to normal since administrator returned. Administrator will certify all records will be organized.
8
9
10
11
12
13
14
This deficiency was evidenced by the following: Staff confirmed records were disorganized when TM1 was operating the facility. Also the MARs reviewed confirmed the records were not being completed as required.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20210108112826
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: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2021
Section Cited
CCR
87307(a)(3)(F)
1
2
3
4
5
6
7
Personal Accommodations and Services (a) The following provisions shall apply:
(3) The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(F) Basic laundry service (washing, drying, and ironing of personal clothing).

1
2
3
4
5
6
7
As of 1/5/21 the administrator had returned full time. Regular staff have returned since TM1 was operating. Administrator indicated the full-time laundry staff is back to work. Interviews conducted revealed regular staff returned once administrator returned to the facility. Administrator will certify laundry staff have returned and are doing laundry regularly.
8
9
10
11
12
13
14
This deficiency was evidenced by the following: 1 resident stated there was insufficient staff to do laundry when TM1 was operating the facility. Staff reported residents complained about laundry not being done and also that there was no on assigned to do laundry when TM1 was there.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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 Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210108112826

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: 45DATE:
05/26/2021
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Lydia Pabion, AdministratorTIME COMPLETED:
10:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator is not present for a sufficient number of hours.
Staff are not meeting the minimum qualifications required by licensing.
Staff are not meeting residents’ health related services.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint investigation for the allegations listed above. LPA met with Lydia Pabion, administrator and explained the reason for the visit. The initial complaint visit was conducted on 1/19/21.

The investigation revealed the following: On 12/16/20, Temporary Manager #1 (TM1) started to operate the facility due to several staff contracting COVID-19. On 12/20/20, Temporary Manager #2 (TM2) took over the operation of the facility due to issues with the way TM1 was operating.

Allegation: Administrator is not present for a sufficient number of hours. It’s alleged TM2 was not at the facility a sufficient number of hours to keep the facility operating properly. Residents interviewed did not corroborate the allegation. Residents indicated the facility started operating smoothly once TM2 arrived at the facility and indicated TM2 was often at the facility. Staff interviewed also indicated TM2 was often at the facility and the facility started operating properly when TM2 arrived. Based on information obtained, the allegation is unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20210108112826
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: 05/26/2021
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
26
27
28
29
30
31
32
Allegation: Staff are not meeting residents’ health related services. It’s alleged that staff were not changing Resident #2’s (R2) colostomy bag properly. Staff interviewed indicated they didn’t have information about that issue. R2 has since passed away and therefore, could not be interviewed. Other residents interviewed did not have any information regarding R2. TM2 indicated that when she arrived to the facility, R2 was non-compliant with staff when they attempted to assist R2 with the colostomy bag, but eventually started allowing staff to change the bag. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff are not meeting the minimum qualifications required by licensing. Residents interviewed did not corroborate the allegation. Residents indicated the facility started running smoothly once TM2 arrived to the facility. Staff interviewed also did not corroborate the allegation. LPA obtained proof of staff training from 12/20/20 - 1/15/21. The following topics were covered: COVID-19 protocols, medication policy and procedures, and mental health and well-being awareness. Based on the information obtained, the allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7