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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 03/04/2024
Date Signed: 03/04/2024 03:19:01 PM


Document Has Been Signed on 03/04/2024 03:19 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



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: 97DATE:
03/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Stephanie Funderburg - Administrator TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit at the facility regarding an incident report submitted to the department on 2/21/24. LPA met with Stephanie Funderburg and explained the reason of the visit.

On 2/21/24 incident report was submitted to the department reporting that on 2/21/24 resident #1(R1) was witnessed outside the memory care unit(MCU) on the parking through a window in the parking lot around 9:45am.

During today's visit LPA Flores reviewed the following documents; incident report dated 2/21/24, physician's report dated 12/12/23, resident assessment dated 2/21/24, service appraisal for R1 and activity plan for MCU. R1 was admitted to the memory care unit of the facility on 1/20/24. Physician's report notes R1 under dementia. Resident assessment was updated to note elopement on 2/21/24 and enhanced needs to provide ongoing redirection for exit seeking behavior and assistance with wandering device, which is the same as the initial service appraisal. Per activity calendar residents had fitness at 9:30am and Musical performance at 10:00am. LPA conducted a tour of the MCU and observed all emergency exits to have egress system in working condition, passageway leading from the fenced door of the courtyard was observed with pile wood planks against the side of each wall leaving about a foot and a half space of passageway.
Video surveillance was reviewed, R1 is observed going into the courtyard at 10:16am, reaches the courtyard emergency exit door at 10:17am and pauses. At 10:18am R1 places the walker against the wall and fenced door, uses the walker to step in it and climbs over to the side wall and over the 7ft fenced door over to the other side, climbs down and walks towards the parking lot by 10:22am staff observed R1 and redirected R1 to the MCU.
Interviews with staff revealed there are 3 staff on each shift and 29 residents in the MCU. At the time of the incident one staff was assisting a resident in the wing by the family lounge, the other staff was on break, and the third staff was assisting another resident in the shower room, other residents were with the activity staff in the activity room. (CONTINUED ON LIC 809C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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
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: 03/04/2024
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Per administrator the staff were asked to provide supervision for R1, medications were adjusted by physician after notifying physician of incident, and is currently in the process of hiring an additional staff for the MCU. The facility has created a plan of care for R1 and there are no previous records of R1 elopement.

However, during this visit LPA noted wood planks in the back passageway leading to the parking lot of the exit door from the MCU courtyard. Therefore, deficiencies are noted on LIC 809D per Title 22 Regulations Division 6 Chapter 8.

Exit interview was conducted with Stephanie Funderburg and a copy of this report and LIC 809D was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/04/2024 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2024
Section Cited
CCR
87307(d)(6)

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87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidence by:
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Administrator will remove wood planks and will submit a picture to the department by POC due date 3/11/24.
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Based on observation licensee did not ensure that all passageways were free of obstruction which poses a potential risk to the health, safety, or personal rights of the persons in care.
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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.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
LIC809 (FAS) - (06/04)
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