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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198603566
Report Date:
09/21/2023
Date Signed:
09/21/2023 05:20:11 PM
Document Has Been Signed on
09/21/2023 05:20 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
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
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:
95
DATE:
09/21/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:24 AM
MET WITH:
Gina Lopez - Business Manager
TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA met with Gina Lopez and explained the reason for the visit.
The facility is licensed to serve 116 non-ambulatory and 104 bedridden residents over the age of 60 years old. Facility is a two story building with delay egress system at the main entrance, a lobby, a memory care unit, several common areas indoor and outdoor such as: a library, activity rooms, game room, private dining room, large dining room, 88 resident bedrooms with private bathrooms, shower rooms in the first floor and second floor, and a commercial kitchen.
LPA toured the facility with Gina Lopez and Brianna Goodlet and observed the following:
No large bodies of water were observed. A total of 10 resident rooms were observed with sufficient lighting, furniture and bedding supplies. Bathrooms were observed in working condition, with grab bars, and skid strips/mats. Toilet in room #149 was clog and overflowed when flushed. Water temperature was tested in each bathroom's sink and tested between 107.2 - 117.8 degrees F., which is within the required 105-120 degrees F.
Dementia unit
has a working delay system in each exit door. Ceiling outside the family lounge has a crack of about 14 inches in length and a water mark of about 15x15 inches in width. Disinfecting spray was observed in the dining/kitchenette area in the cabinets without a lock. The faucet's sink (no water) is out of order in the bathroom located in same dining room, bathroom is accessible to residents. Refrigerator in the activity area was observed dirty with spills and water drip tray has water build up as thick as almost 2cm. The dementia patio was observed with a screen door laying on the floor in between sitting area and a 3x2 feet bench was observed in a passage way to an exit door. 3x2ft chairs were observed in passage way outside room #119. Commercial kitchen was observed with different refrigerators/freezers and a walking refrigerator and freezer. Sufficient food was observed for at least 2 days worth of perishables and 7 days of non-perishables. Library was observed upstairs with a cover fireplace. All common rooms for activities were furnished with sufficient lighting.
(CONTINUED ON LIC 809C)
SUPERVISOR'S NAME:
Tony Vasallo
TELEPHONE:
(818) 419-8131
LICENSING EVALUATOR NAME:
Mary G Flores
TELEPHONE:
(323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE:
09/21/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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:
09/21/2023
NARRATIVE
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Evacuation chairs were observed at the bottom of each stairway. Fire extinguishers were observed and last checked on 9/7/23. Carbon Monoxide/Smoke detectors were observed throughout the facility along with a fire sprinkler system. Last fire-emergency drill was provided on 5/24/23. Emergency Disaster Plan was last updated on 9/1/23 on LIC 610E(10/03), which is not
LPA Flores reviewed medication for 9 residents, 5 resident and 5 staff files. Resident #3(R3) has a dementia diagnosed and last physician's report is dated: 3/15/22. Staff #4 and #5(S4-S5) did not have a health screening on file and S4 did not have a TB clearance. First Aid/CPR training was not observed during staff file review. Administrator's First Aid/CPR training expired on 3/23. Administrator Certificate was observed for Brianna Goodlett #6057760740 expiration date: 11/4/22. No pending application was observed in our database. Per Brianna Goodlett a renewal for administrator certificate was not submitted and executive director Erin Mahoney is to be appointed as the new administrator. Licensee is to submit all required documentation within 10 days from this visit.
Deficiencies are noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted with Gina Lopez and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME:
Tony Vasallo
TELEPHONE:
(818) 419-8131
LICENSING EVALUATOR NAME:
Mary G Flores
TELEPHONE:
(323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE:
09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/21/2023
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
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- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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:
09/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in disinfectant sprays were observed in kitchenette's cabinet without a lock in the dementia unit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/22/2023
Plan of Correction
1
2
3
4
Administrator is to submit LIC 9098 certifying facility staff will be train and all cleaning solutions will be made inaccessible to the residents and a plan for staff training is to be submitted by POC due date 9/22/23. Staff training is to be submitted by 9/28/23.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Tony Vasallo
TELEPHONE:
(818) 419-8131
LICENSING EVALUATOR NAME:
Mary G Flores
TELEPHONE:
(323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE:
09/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/21/2023
LIC809
(FAS) - (06/04)
Page:
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Document Has Been Signed on
09/21/2023 05:20 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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:
09/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in S4 does not have a TB clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/28/2023
Plan of Correction
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2
3
4
Administrator will submit a copy of TB clearance by POC due date 9/28/23 to the department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Tony Vasallo
TELEPHONE:
(818) 419-8131
LICENSING EVALUATOR NAME:
Mary G Flores
TELEPHONE:
(323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE:
09/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/21/2023
LIC809
(FAS) - (06/04)
Page:
4
of
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Document Has Been Signed on
09/21/2023 05:20 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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:
09/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in dementia bathroom's faucet sink accessible to the resident in dining room was not working, activity's room refrigerator was observed dirty, and ceiling by the family lounge was observed with water damage and crack, screen door was observed in the dementia courtyard on the floor which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/28/2023
Plan of Correction
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2
3
4
Administrator will ensure the sink's faucet is in working condition, submit a copy of invoice/work order and picture for the following: the faucet's sink functioning, repaired ceiling, and clean refrigerator to the department by POC due date 9/28/23. Screen door was removed by Gina Lopez from the floor at the time of the visit.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in toilet in room #149 was clogged and overflowed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/28/2023
Plan of Correction
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2
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Administrator will submit an invoice/work order for repairs in room #149 related to the toilet to the department by POC due date 9/28/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Tony Vasallo
TELEPHONE:
(818) 419-8131
LICENSING EVALUATOR NAME:
Mary G Flores
TELEPHONE:
(323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE:
09/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/21/2023
LIC809
(FAS) - (06/04)
Page:
5
of
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Document Has Been Signed on
09/21/2023 05:20 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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:
09/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 5 staff files review did not have a current CPR on file, Brianna Goodlett CPR/first aid expired on 3/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/28/2023
Plan of Correction
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2
3
4
Administrator will submit CPR/first aid cards for 5 staff by POC due date 9/28/23.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in LIC 610E(10/03) was reviewed which does not meet the updated emergency disaster plan LIC 610E(12/21) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/28/2023
Plan of Correction
1
2
3
4
Administrator will submit LIC 610E(12/21) or a version that meets all requirements to the department by POC due date 9/29/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Tony Vasallo
TELEPHONE:
(818) 419-8131
LICENSING EVALUATOR NAME:
Mary G Flores
TELEPHONE:
(323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE:
09/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/21/2023
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
09/21/2023 05:20 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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:
09/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 5 files review, R3 does not have an updated physician's report, last report 3/15/22 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/28/2023
Plan of Correction
1
2
3
4
Administrator will obtain a current physician's report and submit a copy to the department by POC due date 9/28/23.
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in passageways located in the first floor, to the right of the dementia courtyard and outside room #119 have a bench and chairs obstructing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/28/2023
Plan of Correction
1
2
3
4
Administrator will clear the passageways and submit a picture to the department by POC due date 9/28/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Tony Vasallo
TELEPHONE:
(818) 419-8131
LICENSING EVALUATOR NAME:
Mary G Flores
TELEPHONE:
(323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE:
09/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/21/2023
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
09/21/2023 05:20 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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:
09/21/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(g)
87211 Reporting Requirements: (g)The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in listed administrator Brianna Goodlett does not have a current administrator certificate per administrator Erin Manohey is assuming the role and the department was not notify of this change which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/29/2023
Plan of Correction
1
2
3
4
Administrator will notify the department of change and submit pertinent documents to make the change by POC due date 9/29/23.
Type B
Section Cited
CCR
87412(b)(2)
87412 Personnel Records: (b) Personnel records shall be maintained for all volunteers and shall contain the following:
(2) Health screening documents as specified in Section 87411(f).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff do not have a health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/28/2023
Plan of Correction
1
2
3
4
Administrator will obtain a health screening for the S4 and S5 and will submit a copy to the department by POC due date 9/28/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Tony Vasallo
TELEPHONE:
(818) 419-8131
LICENSING EVALUATOR NAME:
Mary G Flores
TELEPHONE:
(323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE:
09/21/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/21/2023
LIC809
(FAS) - (06/04)
Page:
8
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