198603566-2-15-2025-28-AS-TVAO-DDZUGU-20250218143454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 02/15/2025
Date Signed: 02/15/2025 10:55:42 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
01/06/2025 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250106121829

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:	02/15/2025
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Michelle Castillo - Community Liason		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff do not respond to resident's call for assistance
Staff did not notify resident's responsible party of fall
Staff do not ensure facility is free of bad odors
Staff are not safeguarding resident's belongings
Staff do not ensure resident has privacy in their room
Staff did not assist resident after a fall
Staff did not notify responsible party of resident’s room change
Staff’s negligence let to resident’s fall

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 Michelle Castillo and explained the reason for the visit.

The investigation consisted of the following: On 1/7/25 LPA conducted an initial investigation visit, conducted a tour of the facility, observed 10 random resident rooms, and common areas. LPA interviewed 10 residents and 9 staff. LPA requested copies of incident reports for resident #1(R1) between November 2024 and January 2025, identification and emergency sheet, admission agreement, physician’s agreement, resident personal property and valuables sheet, service plan for resident #1(R1). On 1/13/25 Administrator emailed pendant call log for January for R1.

(CONTINUED ON LIC 9099C)

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: 02/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2025

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-20250106121829

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: 02/15/2025

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff do not respond to resident’s call for assistance, and Staff did not assist resident after a fall. It is alleged R1 fell between 12/30/24 and 1/1/25, and pressed the call button for assistance, and staff did not come to assist. Interviews conducted with residents revealed staff have responded to resident’s pendant call and assisted them when needed. Interviews with staff revealed staff respond to the pendant call as soon as possible. Per staff, it may take staff longer to respond if they are assisting other residents with something they cannot leave unattended. Documents review revealed pendant call was pressed for R1 on 1/1/25 at 5:19pm, front desk acknowledges R1 at 5:30pm, and a staff responded and clear pendant call at 5:52pm. Between 12/30/24-12/31/24, R1 pressed the pendant call button 7 times and each was cleared by a staff. There are no incident reports or notes to note R1 fell on/or before 1/1/25 and requested assistance. Although R1 pressed the pendant button on 1/1/25 it is uncertain the reason of the call as residents use the pendant call for assistance with different things as well as for emergencies. Desk acknowledges the call to the residents to ensure the immediate need and proper response.

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 notify resident’s responsible party of fall. It is alleged responsible party was not notified by staff of the fall. Interviews conducted with residents revealed staff either notifies or are certain staff will notify responsible parties if an incident occurs. Interviews with staff revealed when a fall occurs the Med-Tech notifies the responsible party/family of the incident. Documents review revealed R1 is self-responsible, per Emergency Information Sheet signed and dated on 9/28/24. Per incident report dated 1/3/25, R1’s family member was contacted and notify of incident. Per incident report dated 1/5/25, R1’s family member was contacted. Notes on internal incident report dated 1/5/25 note staff was unable to contact family member or leave a voice message after three attempts.

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 do not ensure facility is free of bad odors. It is alleged that the hallway smelled of feces and urine. Interviews with residents revealed the facility does not have bad odors throughout. (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: 02/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250106121829

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: 02/15/2025

NARRATIVE

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Interviews with staff revealed odors are only noticed when a resident with incontinence has had a bowel movement or urinated. Caregivers stated to clean residents timely and ensure that items are properly disposed, and contact housekeepers if additional cleaning is necessary. On 1/7/24 LPA conducted a tour of the facility and did not notice any bad odors throughout the facility.

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 are not safeguarding resident’s belongings. It is alleged a blood pressure machine purchase by R1’s representative was missing. Interviews conducted with residents revealed residents have not lost any items. One resident stated to have misplace items and staff assisted to find them. Interviews with staff revealed residents usually report to staff when they lose something, and residents have not reported any lost items within the last two months. LPA reviewed R1’s Resident Personal Property and Valuables sheet dated and signed on 9/27/24 and notes R1 “decline to track personal property”. Although the item may have gotten lost, there are no documents that record the missing item and there were no reports to staff of the item getting lost per interviews conducted.

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 do not ensure resident has privacy in their room. It is alleged that staff do not knock before entering the room. Interviews with residents revealed staff knock at the door before entering their room. Interviews with staff revealed staff knock at the door before entering the room and let the residents know they are coming in. On 1/7/25 during the tour of the facility, LPA observed staff knock before entering each room visited. LPA also observed other staff knock at the door before entering the rooms to check on residents.

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.

(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: 02/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20250106121829

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: 02/15/2025

NARRATIVE

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Regarding allegation: Staff did not notify responsible party of resident’s room change. It is alleged staff did not notify responsible party of R1’s room change. Interviews conducted with residents revealed residents believe their family members will be notify of any incidents or changes regarding their care. Interviews with staff revealed Med-Tech or administrative staff are the ones who notify family members of incidents or changes in the residents’ care. Per administrator R1 was aware that a room change will take place and R1’s family member was present during the notification of the last room change. Document review revealed Emergency Information Sheet signed and dated on 9/28/24, notes R1 is self-responsible. There were no emergency contacts listed other than R1’s physician. Due to records noting R1 is self-responsible the facility is not responsible for notifying additional parties.

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’s negligence let to resident’s fall. It is alleged R1 fell on 1/5/25 due to staff not locking the brakes on the wheelchair. Interviews conducted with residents revealed staff ensure residents safety. Residents have observed staff locking wheelchair when assisting residents to the dining room or other places. Interviews conducted with staff revealed staff are familiar with safety precautions for residents using a wheelchair and ensure that the wheelchair brakes are lock when they come to a full stop. Documents review revealed, incident report dated 1/5/25 notes R1 fell while attempting to scoot self in the wheelchair while staff were assisting to push R1’s wheelchair in their apartment. Facility staff called emergency personnel and R1 refused to go to the hospital. Although, R1 did suffer a fall on 1/5/25 there is no evidence to support R1 fell due to wheelchair brakes being unlock due to staff neglect. 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 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: 02/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2025

LIC9099 (FAS) - (06/04)

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