198603566-10-1-2026-28-AS-DKOI-DYFU25-20261001151123

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603566
Report Date: 10/01/2026
Date Signed: 10/01/2026 03:18:51 PM

Document Has Been Signed on 10/01/2026 03:18 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ASTORIA PARK SENIOR LIVING		FACILITY NUMBER:	198603566
ADMINISTRATOR/ DIRECTOR:	MARIA QUIZON		FACILITY TYPE:	740
ADDRESS:	925 EAST VILLA STREET		TELEPHONE:	(626) 796-4303
CITY:	PASADENA	STATE: CA	ZIP CODE:	91106
CAPACITY: 220		CENSUS: 156	DATE:	10/01/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:55 AM
MET WITH:	Khatera Bahadory, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	03:20 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit. LPA met with the Executive Director, Khatera Bahadory and LPA explained the purpose of the visit. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. The facility is licensed to serve 104 ambulatory and 116 non-ambulatory residents, 104 residents may be bedridden. Facility has an approved hospice waiver for 25 residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs).

Operational Requirements: The facility has a fire clearance in place. Facility does not handle resident monies. Valid Liability insurance in place. Last Fire drill was conducted on 9/18/2026 and Disaster Drill was conducted 8/21/2026.

Physical Plant/Environment Safety: The facility is a 2-story building consisting of 119 resident rooms, Memory Care Unit, 2 activity rooms with fireplaces, library, game room, beauty salon, private dining room, dining room, shower rooms on the 1^st and 2^nd floors, outdoor courtyards with shaded areas, employee lounge, and offices. Resident rooms have required furniture, bedding, linens, and lighting. LPA observed thirteen (13) randomly selected resident bedrooms and thirteen (13) randomly selected resident bathrooms. Resident rooms have required furniture, bedding, linens, and lighting. The interior and exterior physical plant was inspected. [Continue to LIC809-C]

David Sicairos
Daniel Konishi
	DATE: 10/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ASTORIA PARK SENIOR LIVING	FACILITY NUMBER: 198603566
	VISIT DATE: 10/01/2026

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Physical Plant/Environment Safety: Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. Sharps are secure and inaccessible to residents. The signal system was tested and is operational. Water temperature readings measured between 109.1 degrees F to 117.1 degrees F which is within the required 105 - 120 degrees Fahrenheit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. LPA observed a fireplace in the 2^nd floor library that was closed and inaccessible to residents. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. The last fire inspection was conducted on 8/28/26 by Pasadena Fire Department.

Staffing: A total of 100 staff members provides care and supervision to the clients.

Personnel Records/Staff Training: LPA reviewed ten (10) staff files which included Personnel Record, valid First Aid/CPR/AED training, Criminal Background Clearance, Health Screening, TB Clearance, Employee Rights, Medication Administration Training, Dementia Training, valid Food Handler’s Certificate, and Staff training. Administrator certificate expires 12/14/2027.

Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted. The facility provides internet service to all residents and have access to the facility phone.

Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed.

Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Executive Chef has a current Food Handling Certificate.

Incident Medical and Dental: LPA reviewed eleven (11) residents’ medications. Medications are given as prescribed. Medications are centrally stored and locked in the medication cart. Resident medications which are centrally stored contain 30-day supply of medications. Medical and dental transportation is provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026

LIC809 (FAS) - (06/04)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ASTORIA PARK SENIOR LIVING	FACILITY NUMBER: 198603566
	VISIT DATE: 10/01/2026

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Resident Records/Incident Reports: LPA reviewed ten (10) resident files that included the Face Sheet, Identification and Emergency Information, Admission Agreements, Pre-Placement Appraisal, Physician's Report, Ambulatory Status, TB Clearance, Service Plan, Resident Assessment, and Personal Rights.

Disaster Preparedness: The facility has an Emergency and Disaster Plan LIC 610E that has at least two (2) relocation sites. Facility has a First Aid Kit with all required items and Manual. Last Fire drill was conducted on 9/18/2026 and Disaster Drill was conducted 8/21/2026. There are evacuation chairs by the facility stairwells.

Residents with Special Health Needs: There are currently 7 residents receiving hospice services, 30 receive home health services, and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and bed rails physician orders are in file.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit Interview conducted and a copy of the report was provided to the Executive Director, Khatera Bahadory.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2026

LIC809 (FAS) - (06/04)

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