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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 03/19/2024
Date Signed: 03/19/2024 04:41:09 PM


Document Has Been Signed on 03/19/2024 04:41 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: DATE:
03/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:TIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) conducted an unannounced case management visit at the facility regarding incident report submitted to the department on 3/7/24. LPA met wtih Stephanie Funderburg and explained the reason for the visit.

On 3/7/24 facility submitted an incident report to report that on 3/4/24 at 5:30pm staff noticed resident #1 (R1) was not in the community and an exit door was open. R1 was last seen at 5:10pm after finishing dinner.
Interview conducted with administrator and staff revealed after video footage review, R1 used the emergency exit by room #129 in the memory care unit to exit to the parking lot, walked through the parking lot, and jumped over the parking gate to the street. Delay egress system was working, however staff did not hear the device as staff were at the dining room with other residents. Administrator and managers began to search in the area as soon as it was reported R1 was missing and were not able to find R1. Administrator notified Pasadena Police Department and R1's responsible party. Pasadena police department officers found R1 at around 5:48pm and return R1 to the facility. Upon facility's staff physical evaluation, staff noticed a laceration of about 1cm in diameter on the back of R1's head and was send via paramedics to the hospital for further evaluation.
Hospital Discharge dated 3/4/24 notes R1 was seen for an abrasion of scalp and no other head injuries were observed. It is unknown how R1 obtained the abrasion. R1 returned to the facility on the same day. Needs and Care plan dated 3/19/24 was updated with notes of resident has been placed on 24/7 supervision by additional care staff.
LPA observed emergency exit doors with delay egress system in working condition and tested door by #129 which was observed working but with a faint sound. During this visit administrator notified to have communicated the need of a different environment to the family, facility is assisting with seeking better placement for R1. R1 currently has a one-on-one staff to prevent further incidents.
(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: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 03/19/2024 04:41 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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2024
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... additional staff whenever... the needs of the particular residents...
This requirement is not met as evidence by:
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Administrator has placed a one-on-one staff to provide care for R1, is activily assisting with placement in a smaller setting, and has provided training to staff on delay egress and memory care on 3/5/24 and 3/19/24.
Deficiency cleared as of 3/19/24.
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Based on documents reviewed and interviews conducted the licensee did not ensure R1 did not prevent R1 from eloping the facility after first incident which poses an immediate risk to the health, safety, and 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: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3


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: 03/19/2024
NARRATIVE
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On 3/4/24 LPA Flores conducted a case management regarding R1, for incident report submitted to the department on 2/21/24 regarding an incident in which R1 had exit the memory care unit by climbing over the fenced courtyard emergency exit door.

Deficiencies were noted per Title 22 Regulations on LIC 809D.

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

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3