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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 10/20/2025
Date Signed: 10/20/2025 02:27:45 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
06/25/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250625144015
FACILITY NAME:ASTORIA PARK SENIOR LIVINGFACILITY NUMBER:
198603566
ADMINISTRATOR:STEPHANIE FUNDERBURGFACILITY TYPE:
740
ADDRESS:925 EAST VILLA STREETTELEPHONE:
(626) 796-4303
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:220CENSUS: 151DATE:
10/20/2025
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Stephanie Funderburg - AdministratorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent visit to investigate the reported allgeation, met with Administrator Stephanie Funderberg and explained the purpose for todays visit.

On 6/30/25 LPA Wesely conducted the inital 10 day visit and obtained copies of staff/resident rosters, reviewed medication log, interviewed 3 staff and retrieved specific items regarding the complaint investigation allegation.

During todays visit LPA Herrera obtained copies of staff/resident rosters, copies of Resident #1's (R1) MAR (Medication Administration Record) from March-May 2025, LPA reviewed 15 residents medications and conducted interviews with 3 Staff (S1-S3) and 11 Residents.

(Continued on LIC9099-C page)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
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 3
Control Number 28-AS-20250625144015
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: ASTORIA PARK SENIOR LIVING
FACILITY NUMBER: 198603566
VISIT DATE: 10/20/2025
NARRATIVE
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The investigation revealed the following:
Allegation: Staff mismanaged resident's medication.
It is alleged that R1 was out of a routine medication in the month of May 2025 as facility failed to confirm if the medication was discontinued by the doctor. LPA reviewed R1’s MAR for the months of April-May 2025 and observed that on 5/18/25 R1 was not administered 1 of their routine medications with notes stating that a refill was ordered 5/19/25. LPA conducted interviews with 4 staff and 3 of the 4 staff confirmed that there was a glitch in the MAR that is used through the pharmacy where it documented the medication as discontinued and resident did not receive their medication but could not confirm for how many days R1 was without the medication. Per the MAR it appears that R1 was without medication for one day (5/18/25) as the MAR was not signed by staff and notes on MAR indicate that on 5/19/25 the medication was refilled. Additionally, LPA reviewed 15 residents medications during todays visit with no errors observed. Interviews were conducted with 11 residents and 10 out of the 11 residents denied the allegation.

Based on LPAs observations, interviews which were conducted and medication review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250625144015
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: ASTORIA PARK SENIOR LIVING
FACILITY NUMBER: 198603566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2025
Section Cited
CCR
87465(a)(4)
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87465 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: (4) The licensee shall assist residents with self-administered medications as needed.
This standard was not met as evidence by:
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*medication was all accounted for during visit*
Administrator confirmed that there has been an in-service training on medication and provided LPA a copy of the training participant log that was on 10/7/25, and a copy of the training materials. POC is cleared
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Based review of R1's MAR on 5/18/25 R1 missed a dose of thier routine Riboflavin medication, when LPA interviewed staff 3 staff confirmed that their was a glitch in the MAR during that time where the medication was listed as discontinued and was reordered the following day.
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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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3