198603566-9-4-2024-28-AS-TVAO-D8YUAN-20240910152501

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 09/04/2024
Date Signed: 09/04/2024 04:04:24 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240827213252

FACILITY NAME:	ASTORIA PARK SENIOR LIVING		FACILITY NUMBER:	198603566
ADMINISTRATOR:	STEPHANIE FUNDERBURG		FACILITY TYPE:	740
ADDRESS:	925 EAST VILLA STREET		TELEPHONE:	(626) 796-4303
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	220	CENSUS: 127	DATE:	09/04/2024
		UNANNOUNCED	TIME BEGAN:	03:23 PM
MET WITH:	Stephanie Funderburg - Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Stephanie Funderburg and explained the reason for the visit.

The investigation consisted of the following: On 8/22/24 LPA Flores conducted a case management visit at the facility regarding the above allegation. During that visit LPA requested copies of the following documents; incident report dated: 8/6/24, report of suspected dependent elder abuse (SOC 341) dated: 8/2/24, Pasadena police department business card with report number, identification and emergency information sheet, physician’s report, pre-placement assessment, needs and care plan for residents’#1-2(R1-R2), notice of employee separation, suspension notice, notice to employee as to change in relationship, personnel record for staff #1(S1), email, and other supporting documents. LPA interviewed 5 staff and 2 residents. On 9/4/24 LPA Flores interview S1 over the phone and delivered findings for this complaint.

(CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240827213252

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/04/2024

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff handled resident in a rough manner. It is alleged S1 assisted R2 aggressively causing R2 to scream in pain. On 7/26/24, staff witness S1 using force while providing assistance to R2 per incident report submitted to the department on 8/6/24. Interviews conducted with staff revealed there were corroborative statements that S1 had pulled R2’s left in a rough manner, while R2 was seating on a wheelchair. The leg was lifted up and then placed in the wheelchair’s footrest causing R2 to scream due to pain. Documents reviewed revealed, S1 had provided assistance to R2 by lifting the leg with force to put it in the wheelchair's footrest, resulting on R2 screaming. LPA was unable to interview residents due to cognitive skills. Facility reported the incident to all pertaining agencies on 8/2/24 and conducted an internal investigation for which there was enough evidence against S1. On 8/2/24, S1 was verbally notified of a suspension and investigation of the incident. An officer from the Pasadena Police Department conducted a visit and left report #PA24-61517 regarding the reported incident. On 8/6/24 a Notice of Employee Separation was created, and S1 was terminated from the facility after the suspension for suspected abuse. On 8/6/24 an incident report was submitted to the department after obtaining all the pertaining information to the facility's internal investigation. No physical injuries were caused to the residents by S1. Interview conducted with S1 did not provide additional information and stated to not have treated the residents in a rough manner.

On 8/22/24 LPA Flores conducted a case management visit regarding the above allegation, during the case management visit LPA provided a deficiency on personal rights due to the suspected abused occurred to the residents in care at the facility. Therefore, no additional deficiencies will be cited on a LIC 9099D during this visit.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 were cited on 8/22/24.

Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC9099 (FAS) - (06/04)

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