198603566-5-21-2023-28-AS-TVAO-CS4SZX-20230523141948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 05/13/2023
Date Signed: 05/21/2023 03:48:55 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
12/23/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20221223091903

FACILITY NAME:	ASTORIA PARK SENIOR LIVING		FACILITY NUMBER:	198603566
ADMINISTRATOR:	GOODLETT, BRIANNA		FACILITY TYPE:	740
ADDRESS:	925 EAST VILLA STREET		TELEPHONE:	(626) 796-4303
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY:	220	CENSUS: 87	DATE:	05/13/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Dana Barcelona - Family Resource Community Partner		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident was hit with an object by an unknown perpetrator resulting in fracture.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation(s). LPA met with Dana Barcelona - Community Partner and explained the reason for the visit.

The investigation consisted of the following: On 12/23/22 LPA Kruz conducted a health and safety check visit, no immediate concerns were observed. LPA Kruz requested the following documents; staff/resident roster, identification and emergency information, physician's report, preplacement appraisal information, care assessment, power of attorney, service plan for resident #1(R1). Investigation Bureau (IB) of the Department conducted the investigation, interviews, and requested additional documents. On 3/16/23 IB investigator Brian Slatic conducted interviews with staff and R1 at the facility. On 5/13/23 LPA Flores delivered findings at the facility.

(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: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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-20221223091903

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: 05/13/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Resident was hit with an object by an unknown perpetrator resulting in fracture. It is alleged a resident at the facility assaulted R1 resulting in a fracture. On 12/22/22 R1 complained to facility staff of chest pain due and a resident assaulting R1. Facility staff contacted 911 due to R1's complaints of chest pain. R1 was admitted to Huntington Hospital due to chest pain. During initial assessment at the hospital, R1 reported to have been assaulted by someone at the facility. Hospital followed protocol and contacted Pasadena Police Department (PPD). Hospital noted R1 was observed with a sternal fracture. On 3/16/23, Interviews with facility staff revealed the following; Administrator stated on 12/22/22 R1 reported chest pain to med-tech, facility staff initially believed it was a heart attack. On 12/22/22 Administrator was contacted by the hospital and was notified there was an injury found on R1. This let Administrator to conduct a review of facility's video system which did not reveal anyone entering R1's bedroom between 12/21/22 6:00pm and 12/22/22 7:30am. Administrator speculated R1's injury may be the result of a fall. Interview with Med-Tech revealed that on 12/22/22, med-tech was notified by caregiver that R1 complained of chest pain and decided to call 911. R1 did not mention anything about an assault at that time. Interview with dining room staff revealed R1 had come out to the dining room, "agitated" and stated, "someone came into my room and hit me on my chest," and point to another resident in the dining room. Interview with morning caregiver revealed there were no notes or reports of any incidents the night before. Caregiver conducted a check on R1 at 6:00am and there were no complaints of chest pain. During the incident in the dining room caregiver attempted to redirect R1 back to R1's room to finish dressing. R1 began complaining of chest pain and having trouble breathing. IB investigator attempted to interview R1 and was unable to collect information regarding the incident due to cognitive skills. Documents review revealed the following; last physician's report dated 7/8/22, notes R1 may be confused, have inappropriate behaviors, and/or have aggressive behaviors. No history of falls or incidents were noted. Incident report and report of suspected elderly abuse was submitted to the department on 12/23/22 by the facility. Police report notes the allegation's were documented but was unable to determined how R1 sustained the injuries. Although, R1 did sustain a fracture sternum and initially identified a perpetrator, the investigation did not find evidence to support that anyone inflicted the injury.

Based on interviews conducted, and documents reviewed, the preponderance of evidence standard has not been met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted with Dana Barcelona Community Partner 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: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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