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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:38:06 PM


Document Has Been Signed on 10/19/2023 12:38 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 LIVINGFACILITY NUMBER:
198603566
ADMINISTRATOR:GOODLETT, BRIANNAFACILITY TYPE:
740
ADDRESS:925 EAST VILLA STREETTELEPHONE:
(626) 796-4303
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:220CENSUS: 97DATE:
10/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Erin Mahoney - AdministratorTIME COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit. LPA met with Erin Mahoney and explained the reason for the visit.

On 10/19/23 LPA Flores delivered findings for a complaint #28-AS-20230328095738. During the investigation the following deficiencies were noted:

87211 Reporting Requirements: On 3/24/23, a resident was found on the corner of Lake and Villa St., by facility's staff who was going home after her shift, and brought the resident back to the facility. Resident #1(R1) was a memory care unit resident, who left the facility unattended. Community Care Licensing did not received an unusual incident report regarding the incident. A copy of incident report or transmission sheet was not provided during the visits conducted of 4/3/23 or 10/19/23. Per regulations incidents are to be reported to the department within 7 days of occurrence.

87705 Care of Persons with Dementia: During document review of the complaint investigation, LPA reviewed physician's report for R1 dates 8/17/21. A copy of transmission sheet for a request of physician's report made to the primary physician was provided dated 3/23/23. Per regulation any dementia resident is to obtain an annual medical assessment. Needs and care plan printed on 10/19/23 notes none for special needs, none for wandering and elopement. R1 had left the facility unattended and per interviews conducted will attempt to exit the memory care unit and no plan was developed to address the situation.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Erin Mahoney and a copy of this report, LIC 809D, and appeal rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/19/2023 12:38 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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2023
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports...: (1)A written report shall be submitted...within seven days of the occurrence of any of the events specified in (A) through (D) below...
This requirement is not met as evidence by:
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Administrator will certify that any incident or occurence will be reported to the department within 7 days of it's occurence and will submit a report for the incident on 3/24/23 by POC due date 10/26/23.
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Based on document review licensee did not ensure incident occured on 3/24/23 with R1 was reported to the department within 7 days which poses a potential risk to the health, safety, or personal rights of the persons in care.
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Type B
10/26/2023
Section Cited
CCR87705(c)(5)

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87705 Care of Persons with Dementia; (c) Licensees who accept and retain residents with dementia shall...: (5) Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually.
This requirement is not met as evidence by:
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Administrator will create a plan to ensure physician's reports are obtained at least annually and needs and care plans are updated at least annually or upon a change in condition occurs, plan is to be submitted to the department by POC due date 10/26/23.

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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.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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