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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:12:38 PM


Document Has Been Signed on 09/26/2024 03:12 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: 131DATE:
09/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Stephanie Funderburg - Administrator TIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit regarding incident report submitted to the department on 9/11/24. LPA met with Stephanie Funderburg and explained the reason for the visit.

On 9/7/24 LPA Flores received incident report to notify the department of incident occurred on 8/31/24.
Per incident report, on 8/31/24 at around 2:10pm resident #1(R1) left the memory care unit, had a conversation with lobby staff and left the facility unattended. Upon memory care staff conducting rounds they noticed R1 was not found. Staff contacted police department to request assistance. Police department notify facility staff R1 was found on the street and will be return to the facility. R1 was returned to the facility at around 5:10pm.

LPA conducted interviews with 2 staff, per interviews conducted Lobby staff was not aware of R1 being a memory care resident. Per wellness director, upon checking the egress doors in memory care they were working, it is unknown why the staff were not aware R1 had exit the memory care, lobby staff is provided a binder with pictures of the residents that are not to leave the facility unattended to assist with identifying them. On 9/7/24 Lobby staff was given a final warning notice regarding the incident. On 9/10/24 Wellness Director provided training to staff regarding "Memory Care Secure doors, door checks", and place other measurements in place. Per physician's report R1 dementia is other treated condition and is not to leave the facility unattended.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 809D and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
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 09/26/2024 03:12 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: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2024
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... additional staff whenever... the needs of the particular residents...
This requirement is not met as evidence by:
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Administrator provided in-service training to staff on 9/10/24 regarding securing doors, conducting door checks. Facilty has put in place a log to ensure egress system is working each day in the memory care unit, and staff was given a warning. Deficiency cleared as of 9/26/24.
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Based on documents reviewed and interviews conducted the licensee did not ensure R1 did not elopped from the facility 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.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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