198603566-12-12-2024-28-AS-TVAO-DBWRN9-20241213120954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 12/12/2024
Date Signed: 12/12/2024 10:01:39 AM

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 LIVING		FACILITY NUMBER:	198603566
ADMINISTRATOR:	STEPHANIE FUNDERBURG		FACILITY TYPE:	740
ADDRESS:	925 EAST VILLA STREET		TELEPHONE:	(626) 796-4303
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	220	CENSUS: 130	DATE:	12/12/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Stephanie Funderburg		TIME COMPLETED:	09:00 AM

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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*This is a corrected version of report dated 11/26/24 to reflect unsubstantiated finding correctly on LIC 9099A*

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 Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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-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: 12/12/2024

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 Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC9099 (FAS) - (06/04)

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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: 12/12/2024

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.

Deficiency was noted on LIC 9099D on report dated 11/26/24.

Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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
11/20/2024 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20241120082237

FACILITY NAME:	ASTORIA PARK SENIOR LIVING		FACILITY NUMBER:	198603566
ADMINISTRATOR:	STEPHANIE FUNDERBURG		FACILITY TYPE:	740
ADDRESS:	925 EAST VILLA STREET		TELEPHONE:	(626) 796-4303
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	220	CENSUS: 130	DATE:	12/12/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Stephanie Funderburg		TIME COMPLETED:	09:00 AM

ALLEGATION(S):

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Staff did not report outbreak to required agencies

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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-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: 12/12/2024

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 Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC9099 (FAS) - (06/04)

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