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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 10/25/2024
Date Signed: 10/25/2024 01:14:42 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-20240827104328
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: 129DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Stephanie Funderburg - Administrator TIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Stephanie Funderburg and explained the reason for the visit.

The investigation consisted of the following: On 8/27/24 LPA conducted an initial complaint investigation visit, conducted a health and safety check visit, requested copies of recent death reports, physician’s reports, and other pertaining documents to the complaint for resident #1(R1). LPA interviewed 5 residents. On 9/26/24 LPA interview 1 staff and observed facility's van during another visit at the facility. On 10/3/24 LPA conducted a subsequent visit, interviews 5 additional residents, 6 staff and requested copies of physician’s report, hospital discharge documents for resident #2 (R2) and #3(R3), and facility’s menu. On 10/7/24 LPA requested Pasadena’s Fire Department service log. On 9/26/24 LPA observed facility’s van. On 10/25/24 LPA Flores conducted a visit and deliver findings for the above allegation.
(CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 5
Control Number 28-AS-20240827104328
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: 10/25/2024
NARRATIVE
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The investigation revealed the following: Regarding allegation: Staff did not seek medical attention for resident in a timely manner. It is alleged R1 waited 20 minutes before paramedics arrived. On 8/1/24, while getting into the facility’s van to go on an outing, R1 injured the knee while lifting self into the van. Due to this incident R1 needed medical attention to be requested. Interviews conducted with residents revealed they have received medical assistance in a timely manner or are certain that they will get assistance with obtaining medical care in a timely manner. Interviews with staff revealed staff was with R1 during the incident. R1 stated to be hurt and Wellness coordinator attempted to assess R1 but R1 did not wanted to be touch. Staff brought a chair to have R1 seat while waiting for paramedics. However, R1 refused. Per staff paramedics were called right away and arrived within 15 minutes of the incident. At the time of the incident there were two residents that witnessed the incident. The residents stated R1 waited less than 15 minutes and no more than 30 minutes. Document review revealed, an incident report dated: 8/6/24 notes that on 8/1/24 R1 “was not able to bare weight on leg while getting into facility’s van” at approximately around 11:30am and 911 was called by staff. Pasadena’s Fire Department service log notes the service call was received at 12:29pm. Fire department responded and service with transport to the hospital within 15 minutes of the call. Per documents review facility staff had a delay of an hour to obtain emergency services/medical attention for R1, who sustained a fracture while getting into the facility’s van. Therefore, the allegation is substantiated.

Based on LPAs interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, 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: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240827104328
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: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents...:(a) ... facilities for the elderly shall have ... personal rights: (4) To care, supervision, ... meet their individual needs ... by staff that are sufficient in...qualifications, and competency to meet their needs.
This requirement is not met as evidence by:
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Administrator will provide training to facility's staff in timely medical attention, will provide a copy of staff log, description, duration of training, and will submit to the department by POC due date 9/26/24.
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Based on interviews and documents reviewed licensee did not ensure R1 was provided with timely medical care during the incident by delaying the care by an hour which poses an immediate personal right, health, or safety risk to 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: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
08/27/2024 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240827104328

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: 129DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Stephanie Funderburg - Administrator TIME COMPLETED:
01:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure facility van was accessible for residents to get in
INVESTIGATION FINDINGS:
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3
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5
6
7
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9
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11
12
13
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Stephanie Funderburg and explained the reason for the visit.

The investigation consisted of the following: On 8/27/24 LPA conducted an initial complaint investigation visit, conducted a health and safety check visit, requested copies of recent death reports, physician’s reports, and other pertaining documents to the complaint for resident #1(R1). LPA interviewed 5 residents. On 9/26/24 LPA interview 1 staff and observed facility's van during another visit at the facility. On 10/3/24 LPA conducted a subsequent visit, interviews 5 additional residents, 6 staff and requested copies of physician’s report, hospital discharge documents for resident #2 (R2) and #3(R3), and facility’s menu. On 10/7/24 LPA requested Pasadena’s Fire Department service log. On 9/26/24 LPA observed facility’s van. On 10/25/24 LPA Flores conducted a visit and deliver findings for the above allegation.
(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240827104328
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: 10/25/2024
NARRATIVE
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The investigation revealed the following: Regarding allegation: Staff did not ensure facility van was accessible for residents to get in. It is alleged R1 couldn’t get into the van due to it not having any steps to use to climb into, and instead using a kitchen stool to get into the van. Interviews conducted with residents revealed the facility uses a step to assist residents into the van's step. However, residents on wheelchairs or walkers are assisted into the van through the wheelchair lift. Residents that witness the incident stated the step was placed in the cement and had no issues getting into the van while using it. Interviews with staff revealed the step is a commercial stepping stool which is used to assist the residents get into the van. Driver present at the time of the incident stated to have place the stool in the pavement next to the facility’s van step, across from the curve of the sidewalk. Driver stated to have offer to use the lift to assist R1. However, R1 had chosen to use the step to get into the van. On 9/26/24 LPA observed facility’s van. The following observations of the van were noted, the van is in good repair, with a build-in step inside the van by the side door. Step is in good repair. The van has a wheelchair lift in the back, also in good repair. Stepping stool is a commercial grade step which measures approximately 16 in. by 12 in. Although R1 was injured while stepping on the stepping stool, the facility provided the stepping stool as additional support for the residents, the van and step were in good repair, stepping stool was placed in a flat surface when the incident occurred. Therefore, the allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5