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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 09/06/2024
Date Signed: 09/06/2024 03:29:24 PM


Document Has Been Signed on 09/06/2024 03:29 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: 128DATE:
09/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Stephanie Funderburg - Administrator TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted a case management visit in relation to complaint control #28-AS-20240905092935, LPA met with Executive Director Stephanie Funderburg and explained the purpose for visit.

During the complaint investigation for the above referenced complaint number, LPA reviewed documents regarding the recent Covid out break and observed that the facility failed to inform the Department of the Covid outbreak within the 24 hour reporting requirement. LPA reviewed the Daily Covid-19 Report that indicated that 2 residents tested positive on 8/20/24, 1 resident tested positive on 8/23/24, and 1 resident tested positive on 8/24/24, and 2 residents tested positive on 8/25/24. LPA reviewed Special Incident Reports (SIR's) that were sent to the Department for those individuals and observed that the fax transmittal dates were from 8/30/24. Therefore, there were multiple Covid cases that were not reported within the 24 hour reporting requirement for epidemic outbreaks, this will be cited on the LIC809-D.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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 09/06/2024 03:29 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: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2024
Section Cited
CCR
87211(a)(2)

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87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
This requirement is not met as evidence by:

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Licensee/Executive Director will review the cited regulation in its entirety and confirm that moving forward the facility will report occurences such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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Based on documents reviewed licensee did not report the epidemic outbreak to licensing within the 24 hour reporting requirement, as multiple residents tested positive for Covid-19 (5) days prior to reporting to licensing, which poses a potential risk to the health, safety, or personal rights of the persons in care.
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A copy of the signed Proof of Correction Form LIC9098 must be emailed to LPA by POC due date. This form will serve as an agreement that the regulation has been reviewed and understood.
(tena.herrera@dss.ca.gov)

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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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