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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 11/22/2025
Date Signed: 11/22/2025 10:16:55 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
11/04/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251104120932
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: 149DATE:
11/22/2025
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Stasha ProvittTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff are not administering residents' medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Community Director Stasha Provitt who assisted with today’s visit.

The investigation consisted of the following: During the initial visit conducted on 11/06/2025, LPA interviewed Executive Director, Staff 1-staff 3 (s1-S3) and residents 2- residents 10 (R2-R10). LPA obtained copies of the following documents: Staff roster, resident roster, R1’s physicians reports, identification information (LIC 601), orders for medication, hospital discharge paperwork with updated medication, and Medication distribution log. LPA also did random medication checks and obtained documents for residents’ medication distribution. During today’s visit LPA Gutierrez delivered findings.

SEE LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2025
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 3
Control Number 28-AS-20251104120932
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ASTORIA PARK SENIOR LIVING
FACILITY NUMBER: 198603566
VISIT DATE: 11/22/2025
NARRATIVE
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In regard to the allegation” Staff are not administering residents' medications as prescribed”, It is alleged that R1 did not receive medication despite documentation stating that he/she did. R1 was not present at the facility for the time medication was marked given. Its is also alleged that R1 was given medication that had been discontinued by physicians During interview with Administrator, and staff two (2) out of four (4) stated that there was a medication error and R1 did not receive medication due to them being away with family for the day even though it was signed off as given. S4 stated that R1 was given discontinued medication because it was put in the medication cart even though it was discontinued. During interviews with residents eight (8) out of ten (10) residents stated that they have had no problems with medication to their knowledge. LPA conducted random medication check on residents’ medication and found errors and discrepancies in all five residents checked.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20251104120932
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 11/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.

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Administrator will conduct training with staff on 87465(a)(4) and the importance of medication given to residents correctly and on prescribed time.
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Based on observations and interviews licensee did not ensure, R1 received the medication prescribed due to R1 not being in the facility also R1 was given discontinued medication by staff which poses an immediate risk to the health, safety, and personal rights of the persons in care.




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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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3