<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 12/06/2025
Date Signed: 12/06/2025 12:21:01 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
11/19/2025 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251119194926
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: 147DATE:
12/06/2025
UNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Stasha Provitt, Community Liason Director TIME COMPLETED:
12:23 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not respond to resident's call button in a timely manner.
Staff left resident on the floor for an extended period of time.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alberto Lopez made subsequent unannounced visit to deliver finding for the above-mentioned allegations. LPA met with Stasha Provitt, Community Liason Director and discussed the purpose of the visit. LPA interviewed seven (7) staff total (S#1 – S#7) and Eleven (11) residents (R#1 -R#11)

On 11/24/2025 Licensing Program Analyst (LPA) Alberto Lopez made an unannounced complaint visit to investigate the above allegations. LPA met with Karine Tomassian, Admissions Coordinator, and discussed the purpose of the visit.

The investigation consisted of LPA taking a tour of facility common area and random rooms, reviewing and obtaining staff and resident roosters, schedule for November 7, 2025, call light log for November 7, 2025, interviews with five (5) staff and Eleven (11) residents. Due to lack of information, requires needs further investigation, LPA will return another day. (Continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2025
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 5
Control Number 28-AS-20251119194926
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: 12/06/2025
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
(continued from 9099)

Allegations: Staff did not respond to resident's call button in a timely manner. It is alledged that resident pressed call pendant due to fall and staff did not respond in timely manner.

- Staff left resident on the floor for an extended period of time. It is alleged that resident was on the floor for an unreasonable amount of time.

On November 7, 2025 at approximately 5:00am, R1 had a fall, hit head on the closet doors and fell to the ground. R1 stated R1 pushed call pendant, and R1 waited for what seemed to be a very long time. Several staff blamed other co-workers for the delay. LPA reviewed the call light log for November 7, 2025, and it showed that R1 pressed the pendant at 4:57:00 AM, at 5:06:11AM, the pendant pressed cleared, 9 minutes and 11 seconds after it was initially pressed. At 5:06:00AM, R2 pressed R2 pendant to get assistance for R1 who remained on the floor. At 5:18:42 it was acknowledged by: desk, front. At 5:30:17 AM, the pendant pressed cleared. Based on records reviewed, the resident spent 9 minutes 11 seconds on the floor or 24 minutes 17 seconds on the floor. Both times are unreasonable for any resident to spend on the floor. One staff member stated it was about 30 minutes that resident spent on the floor. R2 stated it was more like an hour. There is sufficient evidence to substantiate both allegations.

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: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/19/2025 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251119194926

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: 147DATE:
12/06/2025
UNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Stasha Provitt, Community Liason DirectorTIME COMPLETED:
12:23 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have adequate staffing to meet resident's needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alberto Lopez made subsequent unannounced visit to deliver findings for the above-mentioned allegation. LPA met with Stasha Provitt, Community Liason Director and discussed the purpose of the visit. LPA interviewed seven (7) staff total (S#1 – S#7) and Eleven (11) residents (R#1 -R#11)

On 11/24/2025 Licensing Program Analyst (LPA) Alberto Lopez made an unannounced complaint visit to investigate the above allegations. LPA met with Karine Tomassian, Admissions Coordinator, and discussed the purpose of the visit.

The investigation consisted of LPA taking a tour of facility common area and random rooms, reviewing and obtaining staff and resident roosters, schedule for November 7, 2025, Alarm Event Report (call light log) for November 7, 2025, interviews with five (5) staff and Eleven (11) residents. Due to lack of information, requires needs further investigation, LPA will return another day. Exit interview conducted and copy of report provided. (continued on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20251119194926
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: 12/06/2025
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
(continued from 9099A)

The investigation revealed: Allegation Facility does not have adequate staffing to meet resident's needs. It is alleged that the facility does to have enough staff to meet resident’s needs. LPA interviewed seven (7) staff and five (5) of seven (7) staff denied the allegation. LPA interviewed eleven (11) residents and nine (9) of eleven (11) residents agreed that facility could use more staff. LPA reviewed the current schedule, and it shows the facility schedules three (3) to five (5) caregivers plus two (2) to four (4) Med-Techs during the day. The schedule shows the facility schedules two (2) caregivers, one (1) front desk and one Med-Tech during the NOC shift which is 10PM – 6:00AM. Facility appears to have sufficient staff scheduled to meet residents needs. There is not enough evidence to substantiate this 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.

A copy of this report was provided to staff.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20251119194926
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2025
Section Cited
CCR
87415(a)(2)
1
2
3
4
5
6
7
87415(a)(2) - Night Supervision
(a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m....shall be available... to assist in caring for residents.
(2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake....

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will conduct an in-service training regarding call light response and submit POC to LPA by 12/16/2025
8
9
10
11
12
13
14
LPA's interviews with staff, residents and review of facility alarm event report for 11/07/2025 showed that staff did not respond in timely manner and that resulted in R1 spending 9 minutes 11 seconds or 24 minutes 17 seconds on the floor. Both times are unreasonable call light respond times or for any resident to spend on the floor. This poses a potential health and safety risk to residents in care
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5