198603566-10-3-2024-28-AS-TVAO-DAKP4E-20241031105857

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:03:00 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
08/27/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240827104328

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:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Stephanie Funderburg		TIME COMPLETED:	03:17 PM

ALLEGATION(S):

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Questionable deaths
Staff are not providing adequate food service to resident
Staff are not meeting residents needs

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 Stephanie Funderburg and explained the reason for the visit.

The investigation consisted of the following: On 8/27/24 LPA conducted an initial complaint investigation visit, conducted a health and safety check visit, requested copies of recent death reports, physician’s reports, and other pertaining documents to the complaint for resident #1(R1). LPA interviewed 5 residents. On 9/26/24 LPA interview 1 staff during another visit at the facility. On 10/3/24 LPA conducted a subsequent visit, interviews 5 additional residents, 6 staff and requested copies of physician’s report, hospital discharge documents for resident #2 (R2) and #3(R3), and facility’s menu.

The investigation revealed the following: Regarding allegation: Questionable deaths. It is alleged one resident sustained a fall, fractured hip, and a week later passed away and another resident passed away suddenly after leaving the dining room. (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: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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-20240827104328

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: 10/03/2024

NARRATIVE

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Interviews conducted with staff revealed, R2 had trip and fallen in the dining room on 4/18/24. Staff assisted R2, who was send out to the hospital via emergency services. Interview conducted with R2’s family member who was present during the fall revealed R2 made a sudden turn and fell, sustaining a hip fracture. Per family member facility staff assisted right away, paramedics were called, and R2 was send out to the hospital. While at the hospital R2 was not able to obtain surgery for the hip fracture due to other health conditions and passed away on 4/25/24 at the hospital. Documents reviewed revealed, Incident report dated 4/22/24, notes R2 suffered a mechanical fall in the dining room on 4/18/24 at 5:30pm. Paramedics were called and was transferred to the hospital. Service Plan dated 12/28/23 notes R2 is independent, self-care, with occasionally needing verbal cues. Per physician’s report dated 5/1/23 R2 did not have any motor impairments.
Regarding R3, interview conducted with administrator revealed R3 had been at the facility for about 4 weeks and did not show any changes in condition or other signs of distress. On 7/10/24, staff conducting checks found R3 in the room unresponsive. Paramedics were called and R3 was declared death. Documents reviewed revealed the following: Per incident report dated 7/9/24, R3 was found in the room on 7/3/24 at approximately 12pm by a caregiver not responding to verbal commands. R3 was assessed by medication technician, who observed R3 was weak, vomiting, and unresponsive to verbal commands. Emergency services were called and R3 was transfer to the hospital. R3 was hospitalize, received treatment, and return to the facility on 7/8/24. R3’s physician’s report dated: 5/16/24 notes R3 had a history of congestive heart failure. Death report dated 7/10/24 notes, on 7/9/24 R3 was found in their room by a medication technician during check rounds. Paramedics were contacted, arrived at the facility, after evaluating R3 declared time of death at 7:42pm. Death report notes cause of death as cardiopulmonary arrest. Although both deaths were sudden there were no changes in condition, prevention, or lack of staff care that could have prevented the deaths of R2 and R3.

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 providing adequate food service to resident. It is alleged R1 was on a vegan food program. However, R1 was forced to buy own vegan food for the chef to cook and was not provided vegan meals by the facility. Interviews conducted with residents revealed facility facilitates meals to residents’ dietary needs or preferences and are satisfied with the meals provided.
(CONTINUED ON LIC 9099C)

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240827104328

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: 10/03/2024

NARRATIVE

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Interviews with staff revealed facility staff are able to identify residents with special diets, allergies, or meal preferences which they follow to provide the meals to the residents in care. Kitchen staff are aware of R1’s vegan meals preference and arrange for R1 to received vegan meals daily. Interview with Culinary Director revealed R1 had shown a desired for certain products that the facility was not able to accommodate as food produce vendor did not carry does specific items. However, culinary director had accommodated other brands or substitutes to provide the meals for R1. Document review revealed R1’s facility’s nutritional profile dated 3/22/24 notes vegetarian meals. Physician’s report dated 3/21/24 notes R1 has a vegetarian diet with regular textures. Although R1 may have had preferences in vegan items or produce, interviews conducted revealed the facility provided vegan meals for R1 with accommodations of produce they were able to obtain with food company they vendor with.

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 meeting residents needs. It is alleged facility staff are not assisting residents with dementia to seat at the dining room table and wheels of residents in wheelchairs are getting stuck in the elevators’ gaps. Interviews conducted with residents revealed residents feel satisfied with the care and assistance the staff are providing to them. Residents that need assistance with wheelchairs stated to be able to get into the elevator without difficulties and wheels have not gotten stuck in the gaps of the elevator. Interviews with staff revealed, at mealtimes staff remind residents to their usual chair when they seem confused and are not left unattended. Also, staff assisting residents in wheelchairs have not have incidents in which wheels get stuck in between the gaps or the elevators’ doorway. During facility’s tour on 8/27/24 LPA observed facility’s elevators in working condition and no large gaps were observed.

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: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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