198603566-12-12-2024-28-AS-RORN-DBZPPC-20241216102917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 12/12/2024
Date Signed: 12/12/2024 10:03:18 AM

Unsubstantiated

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
11/13/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241113151512

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: 128	DATE:	12/12/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Stephanie Funderburg - Administrator		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff do not prevent inappropriate interactions between residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst conducted a subsequent complaint investigation visit at the facility regarding the above allegation. LPA met with Stephanie Funderburg and explained the reason for the visit.

The investigation consisted of the following: On 11/19/24 LPA Flores conducted an initial complaint investigation visit, requested a copy of staff/resident roster. LPA interviewed administrator, 1 resident, and 5 staff. LPA requested copies of resident’s #1-2(R1-R2) physician’s report, admission agreement, identification and emergency information sheet, needs and care plan, individual service plan. On 11/26/24 LPA Flores interviewed 7 residents. On 12/9/24 LPA interviewed residents’ representatives. On 12/10/24 LPA Flores delivered findings.

The investigation revealed the following: Regarding allegation: Staff do not prevent inappropriate interactions between residents. It is alleged a resident has assault another resident and stalk another resident.

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)

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Control Number 28-AS-20241113151512

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 staff revealed there have been no reports of physical abuse or stalking been made to the staff by R1 or other residents. Staff stated they were aware of friendship established between R1 and R2. Per staff, both residents have spent time with each other in the facility common areas and each other’s rooms. Per administrator, there was an incident with R1’s roommate and R2, since then there have been concerns express by R1’s family that R2 may have become possessive of R1. Medication technicians have noticed that R2 had become involved in R1’s care and reminded R2 that R1 is independent, and staff are aware of the care R1 needs. Staff have observed R2 calling and requesting R2’s assistance, after it was communicated to R2 to keep distance from R1 per family’s request. Facility staff communicate with family representatives regarding the concerns. It was discussed with the families that staff will attempt to keep them separated in the dining room or when R1 expresses it. As well as, to not go into each other’s rooms. Interviews with residents revealed some residents have noticed the friendship between the two residents and agree that now the friendship is not the same. Based on additional interviews conducted allegedly R1 was struck by R2. However, there was no bruise, after the alleged struck. It was discovered the bruising was cause by a vaccine given in R1’s arm. Per interviews, there were statements that R2 is unable to physically hurt R1. R1’s family does not consider R2 as a threat to R1, and stated facility has been providing supervision and reminding R2 to maintain distance from R1.

Documents reviewed revealed R1 and R2 do not have a history of aggressive behaviors or behavioral concerns. Both residents do not have cognitive impairment per physician's reports. Per needs and care plans both residents required minimal care. Although the situation may have presented there is no evidence physical abuse occurred. Facility staff have provided supervision and will continue to record interactions between residents. Therefore, this 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 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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