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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 08/27/2024
Date Signed: 08/28/2024 09:08:15 AM


Document Has Been Signed on 08/28/2024 09:08 AM - 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: 127DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Stephanie Funderburg - Administrator TIME COMPLETED:
01:44 PM
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Licensing Program Analyst (LPA) Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Stephanie Funderburg and explained the reason for the visit.

The facility is licensed to serve 116 non-ambulatory and 104 bedridden residents over the age of 60 years old. Facility is a two story building with a lobby, a memory care unit, several common areas indoor and outdoor such as: a library, activity rooms, game room, private dining room, large dining room, 88 resident bedrooms with private bathrooms, shower rooms in the first floor and second floor, and a commercial kitchen.

LPA Flores conducted a tour of the facility with Mario Henriquez - Maintenance Director and observed the following:
Facility is in good repair indoor and outdoor. Commercial Kitchen was observed and sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. All common areas have furniture that are in good repair. Fireplaces in common areas are covered. Memory care unit(MCU) was observed common areas are clean, an enclosed shaded area was observed, activities room available, egress doors throughout the unit tested and in working condition. Two resident rooms were observed in the MCU a cleaning solution in room #150 bathroom's sink was observed. Ten assisted living resident rooms were observed. All twelve rooms have the required bedding, furniture, sufficient lighting. Water temperature was tested in each resident's bathroom and tested between 108.0 - 117.0 degrees F., which is within the required temperature of 105-120 degrees F. Facility has a sprinkler fire system throughout Fire extinguishers were lasted checked on 9/7/23. Assisted living has multiple courtyards with shaded seating areas. Elevators are in working condition. Stairways have an evacuation chair at the bottom of each stairway. Medication room is inaccessible to the residents.

LPA reviewed medical records for 7 residents, and conducted interviews with 7 residents and 6 staff.
(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: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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: 08/27/2024
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LPA concluded Physical Plant domain during this visit and will return at a different time to conclude annual visit and the remaining domains.

Deficiency has been noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted 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: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/28/2024 09:08 AM - 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: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in a cleaning solution was observed under bathroom's sink in room #150 which is located in the memory care unit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Administrator will removed cleaning solution from room #150 and will provide in-service training to staff regarding keeping cleaning solution inaccessible to all residents with dementia by POC due date 8/28/24.
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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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