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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:09:57 PM

Document Has Been Signed on 09/26/2024 03:09 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/
DIRECTOR:		STEPHANIE FUNDERBURGFACILITY TYPE:
740
ADDRESS:925 EAST VILLA STREETTELEPHONE:
(626) 796-4303
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 220CENSUS: 131DATE:
09/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Stephanie Funderburg - Administrator TIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual continuation inspection visit at the facility. LPA met with an explained the reason for the visit.

During this visit LPA completed the following domains during today's visit:
Infection Control, Operational Requirements, Staffing, Personnel Records/Staff Training, Incidental Medical and Dental, Disaster Preparedness, Residents with Special Health Needs.
  • LPA reviewed Infection Control plan and Emergency Disaster plan both were last reviewed on 7/24/24.
  • A total of (8) staff files were reviewed. Training for staff was reviewed.
  • A hospice file was reviewed.
  • LPA reviewed medication for 7 residents. During medication review LPA observed medication for resident #3(R3) did not have labels on the prescribed medication.
  • Liability insurance was reviewed.

The following domains were completed and/or observed during the initial annual inspection visit of 8/27/24:
Physical Plant/Environmental Safety, Resident Rights/Information, Food Service, Planned Activities, Resident Records/Incident Reports.


Deficiency noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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Document Has Been Signed on 09/26/2024 03:09 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/26/2024 at 02:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in R3's prescribed medication was observed with labels which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2024
Plan of Correction
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Administrator will request that prescribed medication has labels prior to accepting if brought to the faciltiy by familiy or will ensure that centralized stored medication has labels once received from pharmacy and will send pictures of the medication with labels to the department by 10/3/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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