<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:07:45 PM


Document Has Been Signed on 08/22/2024 02:07 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: 126DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Stephanie Funderburg - Administrator TIME COMPLETED:
02:20 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 (LPA) Mary Flores conducted an unannounced case management visit regarding incident report submitted to the department on 8/6/24 and 8/8/24. LPA met with Stephanie Funderburg and explained the reason for the visit.

On 8/6/24 an incident report was submitted to the department regarding a notification of physically abused by a staff towards two residents in the memory care unit. On 8/1/24, two staff stated to have witness, staff #1(S1) hitting resident #1(R1) firmly in the hand on 7/26/24 and using force to provide assistance to resident #2(R2) on 7/29/24. Interviews conducted and documents reviewed by LPA revealed staff had observed S1 slapped/snatched R1's hand as R1 requested for assistance as S1 walked by. As well as on 7/29/24, S1 had provided assistance to R2 by bending down the leg and using force to lift it up resulting on R2 screaming. LPA was unable to interview residents due to cognitive skills. No injuries were caused to the residents due to staff's behavior. Facility reported it to all pertaining agencies and conducted an internal investigation and substantiated the allegation against S1. S1 was notified of a suspension and investigation verbally and via email on 8/2/24. On 8/6/24 a Notice of Employee Separation and staff was terminated from the facility after suspension of suspected abuse. Police department conducted a visit and left report #PA24-61517.

Due to physical abuse observed by staff towards two residents, Deficiency is noted on LIC 809D regarding this incident.

On 8/8/24 an incident report was submitted to the department regarding resident #3(R3) provided Heimlich maneuver assistance after staff noticed R3 was chocking during breakfast in the memory care unit dining room on 8/4/24. LPA interviewed the staff who witness and assisted during the incident. Per staff R3 was on a finely chopped diet and was having breakfast at around 10:00am. Dining server noticed R3 was not breathing and went to call Med-tech for assistance. (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: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
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


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: 08/22/2024
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
26
27
28
29
30
31
32
Med-tech checked on R3 and asked dining server to stay with R3 while staff called 911. Kitchen director went to provided assistance with the incident and attempted to clear the airway by removing food observed in R3's mouth and perform Heimlich maneuver. Med-Tech returned and took over. First responders arrived within 3-4 minutes and took over assisting R3. R3 was transferred to the hospital. LPA reviewed R3's file, per physician's report dated 7/15/24, R3 was on a finely chopped diet. LPA observed observed kitchen staff prepare a finely chopped diet, which consist of dicing all food items served to the residents.

After interviews and documents reviewed facility staff provided assistance to R3 as soon as the incident was observed. No deficiencies noted regarding incident occurred on 8/4/24.

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

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/22/2024 02:07 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: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
CCR
87468.2(a)(8)

1
2
3
4
5
6
7
 Additional Personal Rights of Residents ...(a)... shall have all of the following personal rights:(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator provided in service training to staff regarding resident personal rights, elder abuse, dignity and respect a copy was provided of training during this visit. Deficiency cleared as of 8/22/24.
8
9
10
11
12
13
14
Based on interviews and documents reviewed licensee did not ensure S1 treated R1 and R2 with dignity and respect which poses an immediate risk to the health, safety, or personal rights of the persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3