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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 11/26/2024
Date Signed: 11/26/2024 04:14:09 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
11/20/2024 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241120082237
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: 130DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Stephanie Funderburg - AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not preventing the spread of a communicable disease.
Staff are not following infection control requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced 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 11/22/24 LPA contacted Department of Public Health (PDPH). On 11/26/24 LPA requested a copy of staff/resident roster. LPA requested copies of incident reports of recent incident reports, copies of health department reports, and trainings provided to staff. LPA interviewed 6 staff and 6 residents. LPA conducted tour of facility and observed rooms in isolation.

The investigation revealed the following: Regarding allegation: Staff are not preventing the spread of a communicable disease. It is alleged staff provided care, meals, to residents in isolation and did not perform hand hygiene/glove change procedures.
(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: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 6
Control Number 28-AS-20241120082237
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: 11/26/2024
NARRATIVE
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Interviews conducted with residents revealed 3 out of 6 residents stated staff have been seen wearing gloves and mask while providing care. 2 out of 6 residents stated staff were sometimes not wearing proper PPE when providing care. 1 out of 6 residents stated to not be aware of breakout. Interviews with staff revealed staff were informed of symptomatic residents on 11/18/24 and staff implemented wearing PPE, resident isolation, and were provided training. On 11/20/24 a server was observed providing meals in residents rooms without changing gloves in between residents during a visit provided by PDPH. On 11/22/24 staff was observed not implementing proper hand hygiene procedures per PDPH. Training was provided to staff on 11/17/24 on Infection control, and on 11/22/24 training was provided on disinfecting, PPE proper use, and hand hygiene. Although the residents and staff stated to have been following guidance to prevent the spread. Visits conducted by PDPH revealed staff did not follow hand washing and glove changing guidance. Therefore, allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Regarding allegation: Staff are not following infection control requirements. It is alleged facility staff enter a resident’s room with infections disease symptoms and did not use proper Personal Protective Equipment (PPE). On 11/19/24 emergency personnel responded to a call upon entering a resident’s room with symptoms of infectious disease facility staff assisting did not put on proper PPE prior entering the room. Interviews conducted with residents revealed the following 3 out of 6 residents stated staff used proper PPE when entering the rooms to provide care. 3 out of 6 residents either did not observe or remembered whether staff used proper PPE supplies. Interviews with staff revealed staff were provided PPE supplies which were placed outside residents’ rooms that were in isolation. However, staff admitted that during the visit of emergency responder, staff was not wearing PPE when assisting resident with infectious disease symptoms going out to the hospital. During facility’s tour, LPA observed PPE supplies in 3 rooms who are currently in isolation. One staff was observed going into a resident’s room to provide care with face mask under the chin as staff walked to provide care into resident’s room. Although facility has implemented guidelines and provided training to staff, staff did not follow infection control guidance. Therefore, this allegation is substantiated.

(CONTINUED ON LIC 9099C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20241120082237
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: 11/26/2024
NARRATIVE
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Based on LPAs observations, interviews which were conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) 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: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20241120082237
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: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2024
Section Cited
CCR
87470(b)(2)
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87470 Infection Control Requirements: (b) In addition... the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE),,,
This requirement is not met as evidence by:
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 Administrator will schedule training to staff regarding proper use of PPE supplies while providing care to residents by POC due date 11/27/24. Will submit all training provided by 12/2/24.
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Based on observation and interviews licensee failed to ensure staff are wearing PPE supplies when providing care to symptomatic residents and proper use of PPE which poses an immediate risk to the health, safety, or personal rights to the persons in care.
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Type B
12/03/2024
Section Cited
CCR
87470(a)(1)
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87470 Infection Control Requirements: (a) A licensee shall ensure that infection control practices are maintained as follows:
(1) All staff and volunteers shall perform hand hygiene.
This requirement is not met as evidence by:
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Administrator provided training on hand hygiene to all staff on 11/22/24. Deficiency cleared as of 11/26/24.
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Based on interviews conducted with other agencies licensee did not ensure staff were following infection procedures to prevent the spread of the infectious disease which poses a potential risk to the persons safety, health, or 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: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
11/20/2024 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241120082237

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: 130DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Stephanie Funderburg - Administrator TIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
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9
Staff did not report outbreak to required agencies
INVESTIGATION FINDINGS:
1
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3
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5
6
7
8
9
10
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12
13
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced 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 11/22/24 LPA contacted Department of Public Health (PDPH). On 11/26/24 LPA requested a copy of staff/resident roster. LPA requested copies of incident reports of recent incident reports, copies of health department reports, and trainings provided to staff. LPA interviewed 6 staff and 6 residents. LPA conducted tour of facility and observed rooms in isolation.

Regarding allegation: Staff did not report outbreak to required agencies. It is alleged facility staff did not informed emergency personnel of outbreak at the facility. Per Pasadena Department of Public Health (PDPH), an outbreak is considered 2 or more symptomatic or confirmed cases of the virus.

(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: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20241120082237
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: 11/26/2024
NARRATIVE
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Facility reported outbreak to Community Care Licensing (CCLD) on 11/17/24 and to PDPH on 11/18/24. Families, residents, and staff were notified of outbreak on 11/18/24 via letter. On 11/19/24 facility personnel responded to a call at the facility. Staff in charge did not notify personnel of outbreak. Although the facility staff did not informed emergency personnel regarding outbreak at the facility. Facility administration notified CCLD and PDPH within 24 hours of the third resident with symptoms. Regulation stated an outbreak must be notify to CCLD and PDPH.

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: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6