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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603566
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:35:04 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
03/28/2023 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230328095738
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
UNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Erin Mahoney - AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not provide adequate care and supervision to the residents while in care
Staff are blocking the doorway to prevent the residents from coming out
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted a subsequent visit regarding the above allegations. LPA met with Tasha Thompson Front Desk Concierge and explained the reason for the visit. Administrator arrived 10 minutes later.

The investigation consisted of the following: On 4/3/23 LPA Flores conducted a tour of the dementia unit, interviewed staff #1-9(S1 - S9), and residents #1-7(R1-R7), and requested copies of staff/resident roster, and of physician's report, face sheet, and needs and care plan for R1-R6. On 10/19/23 LPA Flores requested physician’s report, needs and care plan, for resident #8(R8) and delivered findings.

The investigation revealed the following: Regarding allegation: Staff did not provide adequate care and supervision to the residents while in care.
(CONTINUED ON LIC (9099C)
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 28-AS-20230328095738
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: 10/19/2023
NARRATIVE
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It is alleged a resident in memory care unit went outside the facility while the staff at the desk where on the phone calling for help. Interviews conducted with residents revealed, 6 out of 7 residents did not know if other residents have exited the memory care unit and gone out to the street or lobby. 1 out of 7 residents was unable to answer due to cognitive skills. Interviews conducted with staff revealed, 6 out of 9 staff interviewed stated that residents have exit the memory care unit unattended either reached the lobby or gone outside. 2 out of 9 staff stated residents have not exit the memory care unit and 1 out of 9 staff was not aware of the situation. Administrator and Wellness Director stated that R8 was found in the corner of Lake and Villa by a staff that was leaving her shift for the day on 3/24/23 and brought back into the facility. On 5/13/23 LPA conducted a complaint visit, during that visit LPA observed a resident exit the memory care unit unassisted into the lobby. Receptionist at that time called for assistance. Documents reviewed note the following: Physician’s report dated 8/17/21, note R8 has wandering behaviors and is unable to leave the facility unassisted. Needs and care plan does not note R8’s wandering behaviors and/or a plan to prevent R8 from leaving the memory care or the facility.

Based on LPAs interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Regarding allegation: Staff are blocking the doorway to prevent the residents from coming out. It is alleged there is always a large wood board that staff put to block the door, so the residents don’t come out of memory care unit. Interviews conducted with residents revealed 3 out of 7 residents stated the doors are not block with any items. 2 out of 7 residents stated the doors are block with a wood board, 2 out of 7 residents were either not sure or unable to answer due to cognitive skills. Interviews with staff revealed 5 out of 9 staff stated the doors are not blocked with a wood board. 2 out of 9 staff stated the doors have been blocked with a wood board to prevent residents from leaving memory care unit. 2 out of 9 staff stated either the doors in the memory care unit are not closed correctly to ensure the egress system works or were not sure about if doors were blocked to prevent residents from leaving. During the tour conducted on 4/3/23 LPA Flores observed exit door by room #129 which exits to the parking lot blocked with a sliding wood board, egress system was observed not working for that door, and door was unlock during the visit. Per administrator there was a leak in the wall adjacent to the door and plumbers had to cut the electricity in the door to work on the door. No plumbers were observed working during the visit or staff around the area supervising.

(CONTINUED ON LIC 9099C)
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
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20230328095738
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: 10/19/2023
NARRATIVE
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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 Erin Mahoney and a copy of this report, LIC 9099D, 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
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20230328095738
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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87705(k)(5)
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87705 Care of Persons with Dementia:
(k) The following... requirements must be met ...(5) Residents who continue to indicate a desire to leave the facility following redirection shall be permitted to do so with staff supervision.
This requirement is not met as evidence by:
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Administrator is to create and provide a plan, review needs and care plans for residents in memory, and/or ensure there is sufficient staff provided in the memory care unit to assist residents that will potentially attempt to exit by POC due date 10/20/23.
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Based on observation, interviews, and documents reviewed licensee did not ensure there is a plan, staff, or assessments for residents in the memory care unit that continued to exit the memory care unit which poses an immediate risk to the health, safety, or personal rights of the persons in care.
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Type B
10/26/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be..., safe,... and in good repair at all times... maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidence by:
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Administrator fixed the door. LPA observed the door and egress system working, there are no boards blocking the door. Deficiency cleared as of 10/18/23.
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Based on observation licensee did not ensure that exit door by room #129 egress system was working at all times which poses a potential risk to the health, safety, or 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.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
03/28/2023 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20230328095738

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
UNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Erin Mahoney - AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff leave a resident soiled for an extended period of time
Staff are using inappropriate language towards the residents
Staff behavior poses as a risk to the residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted a subsequent visit regarding the above allegations. LPA met with Tasha Thompson Front Desk Concierge and explained the reason for the visit. Administrator arrived 10 minutes later.

The investigation consisted of the following: On 4/3/23 LPA Flores conducted a tour of the dementia unit, interviewed staff #1-9(S1 - S9), and residents #1-7(R1-R7), and requested copies of staff/resident roster, and of physician's report, face sheet, and needs and care plan for R1-R6. On 10/19/23 LPA Flores requested physician’s report, needs and care plan, for resident #8(R8) and delivered findings.

The investigation revealed the following: Regarding allegation: Staff leave a resident soiled for an extended period of time. It is alleged there have been two times in the last 30 to 40 days that one resident has “dried poop” all over the body and the caregivers would not clean it.
(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20230328095738
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: 10/19/2023
NARRATIVE
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Interviews with residents revealed, 3 out of 7 residents stated residents are clean and timely changed. 3 out of 7 residents stated they do not require incontinence assistance and 1 out of 7 residents was unable to answer due to cognitive skills. Interviews with staff revealed 9 out of 9 staff stated residents are clean and assisted with incontinence care provided timely. 5 out of the 9 staff stated incontinence care is provided at least between every 2-4 hours or as needed to the residents. Documents reviewed revealed 5 out of 7 residents did not require incontinence care and 2 out of 7 residents need assistance with incontinence care. Needs and care plan noted the residents that need assistance with incontinence care. Other needs and care plan noted reminders needed to be provided to residents that do not required assistance with incontinence care.

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 using inappropriate language towards the residents. It is alleged the caregivers yell in the hallways “saying the f word” at residents. Interviews conducted with residents revealed, 4 out of 7 residents stated staff are respectful and have not use foul language while providing care. 2 out of 7 residents were unable to provide an answer due to cognitive skills and 1out of 7 residents stated it was hard to tell what staff were communicating. Interviews with staff revealed, 8 out of 9 staff stated staff do not use foul language while providing care and 1 out of 9 staff was not sure if other staff use foul language while providing care.

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 behavior poses as a risk to the resident. It is alleged caregivers just sit in the tables on their phone and the residents do whatever they want, even fight. Interviews conducted with residents revealed, 2 out of 7 residents stated staff have been observed in their phones while working. 2 out of 7 residents stated staff are not on their phones while working. 2 out of 7 residents did not know if staff are on their phones while working and 1 out of 7 residents was unable to answer due to cognitive skills. Interviews with staff revealed, 5 out of 9 staff stated staff are not on their phones while providing care and supervision. 4 out of 9 staff stated staff have been observed in their phones during working hours.
(CONTINUED ON LIC 9099C)
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
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20230328095738
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: 10/19/2023
NARRATIVE
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Administrator stated staff communicate with each other with work related stuff via text throughout the day. Therefore, staff will be observe in their phone during working hours.
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 Erin Mahoney and a copy of this report 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
LIC9099 (FAS) - (06/04)
Page: 7 of 7