198603566-9-12-2022-28-AS-MGFS-CJ82G6-20220912172238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 09/12/2022
Date Signed: 09/12/2022 05:22:45 PM

Document Has Been Signed on 09/12/2022 05:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	ASTORIA PARK SENIOR LIVING		FACILITY NUMBER:	198603566
ADMINISTRATOR:	GOODLETT, BRIANNA		FACILITY TYPE:	740
ADDRESS:	925 EAST VILLA STREET		TELEPHONE:	(626) 796-4303
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	220	CENSUS: 83	DATE:	09/12/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Brianna Goodlet - Contact Person		TIME COMPLETED:	04:00 PM

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	Licensing Program Analyst(s) (LPA) Mary Flores, Luis Mora, and Kimberly Ramirez conducted an announced pre-licensing visit at the facility. LPAs met with Brianna Goodlet - Applicant's Contact Person and explained the reason for the visit. Facility has a fire inspection clearance conducted on 7/11/22 for 116 non-ambulatory and 104 bedridden residents over the age of 60 years old. Facility is a two story building with delay egress main entrance, a memory care unit, several common areas, 88 resident bedrooms and bathrooms, shower rooms, and a commercial kitchen. LPAs conducted a tour of the facility with Brianna Goodlet, Brandon Collins Vice President, and Jennifer Siegel Regional Wellness Director and observed the following: Outdoor facility was observed in good repair. No large bodies of water were observed. Commercial kitchen was observed clean and sanitize, sufficient food was observed for at least 2 days worth of perishables and 7 days of non- perishables. Refrigerator(s) temperature was observed under 40 degrees F., and freezer(s) temperature was observed under 0 (zero) degrees F. TV area has a cover fireplace. All rooms have sufficient lighting, furniture, and bedding. Room #145 was observed to have outlet cover plate hanging from lamp cord and room #103 was observed to have a hole in the wall of about 2 inches by 4 inches above the resident's clock. Water temperature was measure in each resident's bathroom and tested between 101.6 - 120 degrees F., which is not within the required 105 - 120 degrees F. Facility has a sprinkle fire system and carbon monoxide detectors were observed in each room. Skid strips/mats were missing in room #141 and #153. Medication was observed in room #256. Cleaning supplies were observed in room #155. All common areas were observed in good repair, with sufficient furniture. Evacuation chairs were observed on top of staircases. First Aid kit was reviewed and had all the required items. Files and medication were reviewed for 9 residents and 7 staff files were reviewed. Facility is following infection control protocols throughout the facility. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: ASTORIA PARK SENIOR LIVING	FACILITY NUMBER: 198603566
	VISIT DATE: 09/12/2022

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PPE supplies were observed sufficient for 30 days. LPAs conducted Composition III with Brianna Goodlet Applicant's Contact Person.

The following items need to be corrected and proof of correction needs to be submitted to licensing within 7 days:

Applicant is to fix the loose outlet cover plate in room #145 and hole in the wall in room #103.
Applicant is to ensure the water temperature is maintain between 105 and 120 degrees F. in rooms #160, 159, 156, 153, 152, 150, 149, 145, 141, 139.
Applicant is to ensure bathrooms in rooms #141 and 153 have skid strips/mats.
Applicant is to ensure resident #1(R1) in room#155 and resident #2(R2) #256 do not store medication in their rooms.

Exit interview was conducted with Brianna Goodlet Applicant's Contact Person and a copy of this report was provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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