198603566-9-26-2024-28-AS-TVAO-D9PN43-20241003100716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:11:51 PM

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
08/22/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240822094827

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: 131	DATE:	09/26/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Stephanie Funderburg		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not prevent resident from sustaining a fracture while in care.
Staff did not prevent the facility from being hazardous resulting in residents sustaining injuries.
Staff did not prevent the facility from being in disrepair.
Staff did not follow physician's order.
Staff did not prevent resident's sleep from being interfered.

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 8/27/24 LPA requested a copy of staff and resident roster. LPA toured the facility with Mario Henriquez – Maintenance Director and observed 12 randomly chosen residents rooms and common areas. LPA interviewed 10 residents and 6 staff and requested the following documents for resident #1(R1) physician’s report, resident assessment, pre-placement, identification and emergency information sheet, order summary report dated 1/31/24, admission agreement, and nutritional information sheet. On 9/26/24 LPA interview (1) staff and delivered findings for this complaint.

Regarding allegation: Staff did not prevent resident from sustaining a fracture while in care. It is alleged R1 injured self and now has a fractured femur due to facility not being safe. Interviews with residents revealed the facility is safe there are no hazardous around and have not witness residents fall or harm.
(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

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-20240822094827

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: 09/26/2024

NARRATIVE

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Interviews with staff revealed R1 was leaving the facility on an outing, facility’s driver assisted R1 standing near R1 and providing hand for support. R1 place her hand on driver and used her left hand on the van’s handle to pull self-up. As R1 was lifting self-up to get into the van, R1 cried out in pain and stated to have “pop my knee”. Staff called emergency services for R1 who arrived right away and was taken to the hospital by paramedics. Documents reviewed revealed, per physician’s report dated 3/21/24, R1 is ambulatory and does not have any physical impairments. Incident report dated 8/6/24 notes R1 was going in an outing and was “stepping into the community bus assisted by facility’s driver. Upon R1 stepping into the bus, R1 stated to have heard a snap in the knee and was unable to bear weight”. A medication technician assessed R1 and 911 was called to send R1 to the hospital. Per preplacement appraisal information dated 3/29/24 R1 had a “prior broken left femur”, hip and knee. Resident Assessment dated 3/20/24 notes R1 is “independent, self care”. Although R1 may have sustained a fracture, the fracture was not due to hazardous or the facility not being safe.

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.

Regarding allegation: Staff did not prevent the facility from being hazardous resulting in residents sustaining injuries. It is alleged the facility is not safe and they are having "things" in places where they shouldn't be causing residents to fall many times and have gotten injured. Interviews with residents revealed they have not observed hazardous materials or construction materials left in hallways or common areas. Interviews conducted with staff revealed there has been some remodeling done at the facility. However, the tools and materials are kept inside the rooms being remodel and not in common areas or corridors. During the tour of the facility LPA observed the remodel rooms. No hazardous materials or tools were observed in the hallways or common areas. Incident reports submitted within the last month to the department note falls due to other reasons.

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.

Regarding allegation: Staff did not prevent facility from being in disrepair. It is alleged shower stopped working and the A/C unit also stopped working. Interviews conducted with residents revealed shower and A/C has been in working condition and had no concerns. (CONTINUED ON LIC 9099C)

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240822094827

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: 09/26/2024

NARRATIVE

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Interviews with staff revealed facility’s A/C has been in working condition and no reports of clogged showers had been made. During facility tour a total of 12 resident rooms were observed and each shower/bathroom was in working condition. Temperature in each room was felt comfortable and A/C was working.

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.

Regarding allegation: Staff did not follow physician’s order. It is alleged resident did not receive physical therapy for eight weeks due to facility lying agency about whereabouts of resident. Interviews with residents revealed residents are assisted as needed with all their needs. Interview with administrator revealed R1 was not receiving physical therapy or had orders for physical therapy. Documents reviewed revealed Skill Nursing order summary report dated 1/31/24 notes R1 was to received physical therapy, “one time only” until 2/25/24. No other physician orders were observed in R1’s file pertaining most recent physician’s order for physical therapy. Resident Assessment dated 3/20/24 notes R1 is independent to coordinate own healthcare and home care appointments.

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.

Regarding allegation: Staff did not prevent resident’s sleep from being interfered. It is alleged resident’s roommate snored loudly and resident could never sleep. Interviews conducted with residents revealed staff responds to residents’ concerns when necessary and have not experience issues with roommates. Interview with administrator revealed, R1 reported the situation. R1’s roommate was moved from room due to residents not getting alone. R1’s roommate was interview and was not able to recall any incidents with roommates. Although the situation may have happened there is not enough evidence to say that the facility did not take action in assisting R1 after reporting R1’s concerns.

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.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024

LIC9099 (FAS) - (06/04)

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