198603566-9-6-2024-28-AS-DSIS-D9AQBN-20240920120147

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 09/06/2024
Date Signed: 09/06/2024 03:30:03 PM

Unsubstantiated

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
09/05/2024 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240905092935

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: 128	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Stephanie Funderburg - Executive Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not preventing the spread of COVID-19.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Stephanie Funderburg - Executive Director and explained the reason for the visit.

The investigation consisted of the following:
LPA obtained copies of Staff and Resident Rosters, Correspondence emails beteween the Executive Director and Department of Public Health, Letters informing Residnets and Responsible/Parties of the Covid Positive results, and exposure. LPA toured facility both 1st and 2nd floors along with the memory care wing. LPA interviewed 5 Staff and 12 Residents.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20240905092935

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: 09/06/2024

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

The investigation revealed the following:
Allegation: Staff are not preventing the spread of COVID-19.
LPA toured facility alongside of Stephanie Funderburg (Executive Director) and Ann-Marie Boersma (Wellness Director) and observed hand sanitizing stations throughout facility, LPA tested the sanitizing stations in common areas and they were operable. There is one resident that was recently on isolation (last day was yesterday), signage of corona virus was at the door and there was a sanitizing station with masks, gloves, gowns, and hand sanitizer outside of their room. LPA observed a storage room in memory care that had sufficient PPE supplies, such as masks, gloves, gowns and hand sanitizer. LPA obtained copies of letters informing Residents and Family/Responsible parties that were sent out, informing them that there have been Covid Positive cases and encouraging all to wear masks, as well as staff. Throughout the tour LPA observed multiple staff and residents without masks, however, given the recent Rescission of Health Officer Order for the City of Pasadena as of March 5,2024, the order requiring masks by personnel, patients, clients and visitors in health care settings issued March 29.2023 by the health officer of the City of Pasadena is rescinded in its entirety, this information was provided to LPA by the Department of Public Health. LPA interviewed 12 Residents and 10 out of 12 Residents denied the above allegation. 10 residents stated that have observed staff wearing masks and have masks and hand sanitizer readily available for them, they also stated that they were informed of the outbreak and encouraged to wear masks. LPA interviewed 5 staff and 5 out of staff denied the above allegation and stated that they have been encouraging masks, sanitizing and have notified residents of the outbreak.

LPA special incident reports that were submitted to licensing, and noticed that the Covid outbreak was not reported per the 24 hour reporting requirement. This will be detailed in a separate case management report.

Based on statements and interviews conducted with staff and residents, review of documents/records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 2