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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 04/03/2025
Date Signed: 04/03/2025 05:00:49 PM

Substantiated


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
03/27/2025 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250327151357
FACILITY NAME:ASTORIA PARK SENIOR LIVINGFACILITY NUMBER:
198603566
ADMINISTRATOR:STEPHANIE FUNDERBURGFACILITY TYPE:
740
ADDRESS:925 EAST VILLA STREETTELEPHONE:
(626) 796-4303
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:220CENSUS: 146DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Stephanie Funderburg - Administrator TIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff administered another resident’s medication to resident resulting resident being admitted to the hospital.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met Stephanie Funderburg with and explained the reason for the visit.

The investigation consisted of the following: LPA requested a copy of staff/resident roster. LPA conducted a medication review of 5 residents. LPA conducted interviews with 7 residents and 6 staff. LPA requested a copy of resident #1(R1)’s physician’s report, admission agreement, identification and emergency information sheet, needs and care plan, medication sheet for the last three months, and Resident #2(R2)’s March medication sheet, and Staff #1(S1)’s initial medication training, corrective action, and in-service training.

The investigation revealed the following: Regarding allegation: Staff administered another resident’s medication to resident resulting resident being admitted to the hospital. It is alleged R1 was admitted to the hospital on 3/27/25 due to staff administering another resident’s medication.
(CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20250327151357
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: 04/03/2025
NARRATIVE
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Interviews with residents revealed 2 out of 7 residents interview stated to have been given the wrong medication and 1 out of the 2 had to go to the hospital for an evaluation. 5 out of 7 residents stated to not have had medication errors. However, 1 out of the 7 stated to have not have medication available for over a week. Interviews conducted with staff revealed S1 had made a mistake by providing R1 the medication of another resident. Per S1 the other resident realized it was not their medication and let S1 know. It was then when S1 communicated with Wellness Director and they follow up with physician and responsible party, who advice R1 be taken to the hospital. Per Administrator, S1 received a corrective action and an in-service training was provided to the medication technicians on 3/27/25. Per documents reviewed R1’s medical assessment dated:4/14/24 notes, R1 is able to manage own medications. Needs and care plan dated: 4/2/25 notes R1 requires assistance with medication, and medication is provided by the medication technician. Medication error was not noted on the medication sheet. However, on 4/2/25 facility staff submitted an incident report in which it was reported that on 3/27/25 S1 provided R1 with the wrong medication and R1 was send out to the hospital. Per R1’s hospital discharge, R1 was seen for a medication problem. S1 was provided initial medication training on December of 2024, and training was retaken on 3/28/25 and 4/3/25. In-Service training was provided by wellness director on 3/27/25 to all medication technicians. Medication review revealed 3 out of 5 residents were missing at least one of their routine medication.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.



Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250327151357
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... staff shall... ensure provision of personal assistance and care...
This requirement is not met as evidence by:
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Administrator provided in-service training to S1 on 3/28/25. Administrator will create a plan to have all medications audit and will submit the plan to the department by POC due date 4/4/25.
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Based on observations and interviews licensee did not ensure, R1 received the correct medication provided by S1 which poses an immediate risk to the health, safety, and personal rights of the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3