Inspection Reports for Astoria Park Senior Living
925 E Villa St, Pasadena, CA 91106, United States, CA, 91106
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to medication management, resident safety including elopement prevention, infection control, and staff training. Several substantiated complaints involved medication errors that posed immediate health risks, physical abuse by staff resulting in suspensions and terminations, and failure to prevent resident elopements, with corrective actions implemented. The facility also had issues with maintenance and cleanliness, particularly in the Memory Care Unit, and lapses in staff first aid/CPR training and safety signage. The most recent inspection on October 6, 2025, cited multiple deficiencies including missing medications, cleanliness problems, and expired staff training. While some complaint investigations were unsubstantiated, the pattern of medication and safety-related deficiencies suggests ongoing challenges, though the facility has taken steps to address staff misconduct and safety risks over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
163% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
70% occupied
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 153
Capacity: 220
Deficiencies: 6
Oct 6, 2025
Visit Reason
An unannounced required 1-year annual inspection was conducted to evaluate compliance with licensing requirements for the Residential Care for Elderly facility serving residents aged 60 and over, including a Memory Care Unit for cognitively impaired residents.
Findings
The inspection found multiple deficiencies including failure to fill certain resident medications, maintenance and cleanliness issues in the Memory Care Unit, missing 'No Smoking-Oxygen In Use' signs in rooms with oxygen tanks, expired or missing staff first aid/CPR training, and lack of mattress pads on most resident beds. Plans of correction were requested with due dates ranging from 10/07/2025 to 11/03/2025.
Severity Breakdown
Type A: 1
Type B: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Resident R1's Acidolphilus Tablet, Calcium 600-Vit D3 500, Clobetasol .05%, Aquaphor 41% ointment medications have not been filled. | Type A |
| Memory Care Unit patio door inoperable, room 152 bathtub faucet leaking, MCU public bathroom door in disrepair, room 132 bathroom wall drywall in disrepair and missing blinds, room 133 missing medicine cabinet mirror. | Type B |
| Room 148 had a soiled incontinence pad on the entrance, MCU public bathroom had feces on toilet, blood on bed/sheets in room 141, MCU shower room floor had feces, and MCU rooms were not clean. | Type B |
| Majority of 26 inspected primarily shared rooms did not have mattress pads on resident beds. | Type B |
| Staff members S3, S5, S7, S8 do not have current 1st Aid/CPR training on file or it is expired. | Type B |
| Rooms 130 and 133 had oxygen tanks but no 'No Smoking-Oxygen in Use' signs posted. | Type B |
Report Facts
Staff count: 90
Residents receiving hospice services: 12
Residents receiving home health services: 59
Medication supply: 30
Fire clearance capacity: 104
Fire clearance capacity: 116
Hospice waiver capacity: 25
Fire inspection date: Apr 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lisa Hicks | Licensing Program Manager | Supervisor and licensing program manager named in the report |
| Michelle Castillo | Business Office Manager | Facility representative met during inspection and during exit interview |
| Stephanie Funderburg | Administrator | Facility administrator named in the report |
Inspection Report
Follow-Up
Census: 152
Capacity: 220
Deficiencies: 1
Sep 19, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on observations made during a complaint investigation visit on 2025-09-02.
Findings
A deficiency was cited due to the licensee's failure to ensure that Resident #2 had routine and as needed medications available, posing an immediate risk to health, safety, and personal rights. Residents reported not needing to ask for the medications, and one resident refused to talk to the Licensing Program Analyst.
Complaint Details
The visit was a follow-up to a complaint investigation conducted on 2025-09-02 regarding missing medications for residents.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Based on medication review and document review, licensee did not ensure that Resident #2 had routine and as needed medication which poses an immediate risk to the health, safety, and personal rights of the persons in care. | Type A |
Report Facts
Census: 152
Total Capacity: 220
Plan of Correction Due Date: Sep 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the unannounced case management visit and medication review. |
| Stephanie Funderburg | Administrator | Met with Licensing Program Analyst during the visit and explained the reason for the visit. |
Inspection Report
Complaint Investigation
Census: 151
Capacity: 220
Deficiencies: 0
Aug 8, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding the allegation that staff prohibit a resident from leaving the facility.
Findings
The investigation found that resident #1 may not leave the facility unassisted according to a physician's report. Interviews with staff and residents mostly denied the allegation, and the facility offers community outings residents can sign up for. There was insufficient evidence to substantiate the allegation, so it was deemed unsubstantiated. No deficiencies were cited.
Complaint Details
The allegation was that staff prohibit resident #1 from leaving the facility. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 220
Census: 151
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Funderburg | Administrator | Facility administrator who assisted during the investigation |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 220
Deficiencies: 0
Jul 24, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-06-16 regarding staff retaining a resident requiring a higher level of care, failure to transport residents to medical appointments, unmet hygiene needs, lack of dignity in staff-resident relationships, and rough handling of residents.
Findings
Based on interviews with staff, residents, and review of records, there was insufficient evidence to substantiate the allegations. Most staff and residents reported that care needs, transportation, hygiene, dignity, and handling were appropriately managed. The allegations were therefore unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff retaining a resident needing higher care, failure to transport residents, unmet hygiene needs, lack of dignity, and rough handling. Interviews with six staff and nine residents generally refuted these claims, and no disciplinary actions were noted.
Report Facts
Staff interviewed: 6
Residents interviewed: 9
Complaint allegations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christian Gutierrez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stephanie Funderburg | Administrator | Facility administrator interviewed during investigation |
| David Sicairos | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 220
Deficiencies: 0
May 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation received on 2025-04-14 regarding physical and mental abuse of a resident while in care.
Findings
The investigation included interviews with the administrator, staff, and residents, and a review of relevant documents. The allegation of abuse was not substantiated due to lack of preponderance of evidence, despite bruises observed on the resident during a shower transfer in March 2025.
Complaint Details
The complaint alleged that Resident #1 was physically and mentally abused by two employees on 2025-03-20 at approximately 7 pm. Interviews and investigation did not find sufficient evidence to substantiate the allegation. Staff denied rough handling and reported no prior signs of abuse before police involvement on 2025-04-15.
Report Facts
Capacity: 220
Census: 147
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met with Licensing Program Analyst during the investigation and provided information related to the complaint |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Fernando Fierros | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 147
Capacity: 220
Deficiencies: 0
May 13, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that facility staff do not ensure a resident eats an adequate amount of food.
Findings
The investigation found that although one resident had decreased food intake and required nutritional shakes, staff assisted the resident with meals and physician follow-ups. Interviews with residents and staff supported that meals were provided adequately. Therefore, the allegation was unsubstantiated.
Complaint Details
The complaint alleged that facility staff did not ensure a resident ate an adequate amount of food, resulting in malnourishment and muscle wasting. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 10
Staff interviewed: 8
Refused meals: 3
Physician visits: 4
Nutrition shakes increase: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Funderburg | Administrator | Facility administrator met during investigation and exit interview |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 147
Capacity: 220
Deficiencies: 1
Apr 29, 2025
Visit Reason
An unannounced case management visit was conducted to follow up on deficiencies observed on 2025-04-03 during a complaint investigation visit related to missing routine medications for three residents.
Findings
The facility was found to have deficiencies related to missing routine medications for residents R1, R2, and R3, which posed a potential risk to their health, safety, and personal rights. The deficiency was cited under LIC 809D per Title 22 Regulations.
Complaint Details
The visit was a follow-up to a complaint investigation conducted on 2025-04-03, which found missing routine medications for three residents. The deficiency was substantiated and cited.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Routine medications were missing for residents R1, R2, and R3, with R1 missing one medication, R2 missing four medications, and R3 missing one medication, not refilled for at least 4 days. | Type B |
Report Facts
Residents with missing medications: 3
Missing routine medications: 6
Plan of Correction due date: Apr 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met with during the inspection and named in relation to the medication deficiency finding. |
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation and follow-up visit. |
| Gabriela Castro | Licensing Program Analyst | Conducted the follow-up case management visit. |
| Tony Vasallo | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 146
Capacity: 220
Deficiencies: 1
Apr 3, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that staff administered another resident’s medication to a resident, resulting in the resident being admitted to the hospital.
Findings
The investigation substantiated the allegation that staff member S1 administered the wrong medication to resident R1, who was subsequently hospitalized. Interviews and record reviews confirmed medication errors, with corrective actions and in-service training provided to staff. Medication review also revealed that 3 out of 5 residents were missing at least one routine medication.
Complaint Details
The complaint was substantiated. Staff administered another resident’s medication to resident R1, resulting in R1 being admitted to the hospital on 03/27/2025. Staff member S1 made the error and received corrective action and training. Medication errors were confirmed through interviews and documentation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide necessary services, resulting in a medication error where resident R1 received incorrect medication posing immediate risk to health and safety. | Type A |
Report Facts
Residents interviewed: 7
Staff interviewed: 6
Residents reviewed for medication: 5
Residents missing routine medication: 3
Medication training dates: 3
Plan of Correction due date: Apr 4, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Funderburg | Administrator | Facility administrator involved in investigation and exit interview |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
| S1 | Staff member | Staff who administered wrong medication to resident R1 |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 220
Deficiencies: 0
Feb 15, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations received on 2025-01-06 regarding staff response to resident calls, notification of falls and room changes, facility odors, safeguarding belongings, resident privacy, and staff negligence related to a resident fall.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations. Staff were observed and interviewed, and documentation reviewed showed appropriate responses to resident calls, notifications to responsible parties, maintenance of facility cleanliness, safeguarding of belongings, respect for resident privacy, and proper safety precautions related to wheelchair use. All allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to respond to resident calls, failure to notify responsible parties of falls and room changes, presence of bad odors, failure to safeguard belongings, lack of resident privacy, and staff negligence leading to a fall. Interviews, observations, and document reviews did not support these allegations.
Report Facts
Capacity: 220
Census: 131
Incident report dates: 3
Pendant call presses: 8
Incident report date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Funderburg | Administrator | Facility administrator involved in providing documentation and information |
| Michelle Castillo | Community Liaison | Met with Licensing Program Analyst during investigation |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Census: 130
Capacity: 220
Deficiencies: 0
Jan 16, 2025
Visit Reason
An unannounced case management - health and safety check visit was conducted regarding the relocation of 2 residents from Foothill Heights Care Center due to mandatory evacuation orders from the Fire Advisory.
Findings
No immediate health and safety concerns were observed during the visit. The facility is fully staffed, medications for the relocated residents are centrally stored and inaccessible, and food and hygiene supplies are adequate. The administrator is working on proper placement for a resident with a prohibited health condition.
Report Facts
Number of relocated residents: 2
Date of last fire drill: Dec 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the unannounced case management - health and safety check visit |
| Michelle Castillo | Community Liaison Director | Met with Licensing Program Analyst during the visit |
| Stephanie Funderburg | Administrator | Facility administrator involved in the visit and exit interview |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 220
Deficiencies: 0
Jan 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not properly storing a resident's personal belongings and that staff did not ensure residents' hygiene needs were being met.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Residents' belongings were observed to be properly stored, and residents were assisted with showers at least twice a week with clean bedding observed. Both allegations were determined to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included improper storage of resident belongings and failure to meet residents' hygiene needs. Interviews with residents and staff, facility tour, and review of service plans showed compliance with care standards.
Report Facts
Capacity: 220
Census: 129
Number of residents interviewed: 10
Number of staff interviewed: 9
Shower assistance frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Funderburg | Administrator | Facility administrator involved in investigation and exit interview |
| Michelle Castillo | Community Liaison Director | Met with Licensing Program Analyst during investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 220
Deficiencies: 2
Dec 12, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff were not preventing the spread of a communicable disease and were not following infection control requirements.
Findings
The investigation found that staff did not consistently follow infection control procedures such as hand hygiene and proper use of PPE, substantiating the allegations. However, the allegation that staff did not report an outbreak to required agencies was found to be unsubstantiated.
Complaint Details
The complaint investigation was substantiated for failure to prevent the spread of communicable disease and failure to follow infection control requirements. The allegation that staff did not report the outbreak to required agencies was unsubstantiated.
Deficiencies (2)
| Description |
|---|
| Staff provided care and meals to residents in isolation without performing hand hygiene or changing gloves between residents. |
| Facility staff entered a resident's room with infectious disease symptoms without using proper Personal Protective Equipment (PPE). |
Report Facts
Residents interviewed: 6
Staff interviewed: 6
Residents stating staff wore gloves and mask: 3
Residents stating staff sometimes did not wear proper PPE: 2
Residents unaware of outbreak: 1
Date staff informed of symptomatic residents: Nov 18, 2024
Date of staff training on infection control: Nov 17, 2024
Date of staff training on disinfecting, PPE use, and hand hygiene: Nov 22, 2024
Date facility reported outbreak to CCLD: Nov 17, 2024
Date facility reported outbreak to PDPH: Nov 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Stephanie Funderburg | Administrator | Facility administrator met with Licensing Program Analyst during investigation and exit interview |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 220
Deficiencies: 0
Dec 12, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff did not prevent inappropriate interactions between residents, including assault and stalking.
Findings
The investigation found no evidence of physical abuse or stalking. Staff were aware of the residents' interactions and took steps to supervise and separate them as needed. The allegation was determined to be unsubstantiated due to lack of evidence.
Complaint Details
The complaint alleged that staff failed to prevent inappropriate interactions between residents, including assault and stalking. The investigation included interviews with staff, residents, and family representatives, and review of medical and care documents. The allegation was unsubstantiated.
Report Facts
Capacity: 220
Census: 128
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met with during investigation and exit interview |
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 220
Deficiencies: 2
Nov 26, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were not preventing the spread of a communicable disease, not following infection control requirements, and did not report an outbreak to required agencies.
Findings
The investigation substantiated that staff failed to follow proper infection control procedures including hand hygiene and PPE use, posing risks to residents. However, the allegation that staff did not report the outbreak to required agencies was unsubstantiated as the facility reported the outbreak to Community Care Licensing and the Department of Public Health within required timeframes.
Complaint Details
The complaint investigation was substantiated for allegations related to failure to prevent the spread of communicable disease and failure to follow infection control requirements. The allegation that staff did not report the outbreak to required agencies was unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staff wear appropriate Personal Protective Equipment (PPE) when providing direct care to residents with contagious diseases. | Type A |
| Failure to ensure all staff and volunteers perform hand hygiene as required. | Type B |
Report Facts
Residents interviewed: 6
Staff interviewed: 6
Deficiency due date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Funderburg | Administrator | Facility administrator met during investigation and named in findings |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 129
Capacity: 220
Deficiencies: 1
Oct 25, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit regarding allegations that staff did not seek medical attention for a resident in a timely manner and that the facility van was not accessible for residents to get in.
Findings
The investigation substantiated that staff delayed obtaining emergency medical attention for resident #1 by about an hour after an injury sustained while entering the facility van, posing an immediate personal right, health, or safety risk. The allegation that the facility van was not accessible for residents to get in was unsubstantiated, as the van and its equipment were found to be in good repair and appropriate steps were used.
Complaint Details
The complaint alleged that staff did not seek medical attention for resident #1 in a timely manner after the resident injured their knee while entering the facility van on 8/1/2024. The investigation found a delay of about an hour in obtaining emergency services, substantiating the allegation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide timely medical care to resident #1 during an incident, delaying care by an hour which posed an immediate personal right, health, or safety risk. | Type A |
Report Facts
Facility capacity: 220
Resident census: 129
Delay in medical attention: 60
Date complaint received: Aug 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Funderburg | Administrator | Facility administrator met with Licensing Program Analyst during the investigation and exit interview |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 220
Deficiencies: 0
Oct 3, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations including questionable deaths, inadequate food service, and staff not meeting residents' needs at Astoria Park Senior Living Facility.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Two resident deaths were reviewed and determined to be sudden but not preventable by staff care. The facility was found to provide meals according to residents' dietary needs, including vegan meals, and residents reported satisfaction with care and assistance, including wheelchair and dining support.
Complaint Details
The complaint investigation addressed allegations of questionable deaths, inadequate food service, and staff not meeting residents' needs. The investigation included interviews with residents, staff, and family members, review of incident and physician reports, and facility observations. All allegations were found to be unsubstantiated.
Report Facts
Facility capacity: 220
Resident census: 131
Complaint receipt date: Aug 27, 2024
Dates of incidents: Apr 18, 2024
Date of death: Apr 25, 2024
Date resident #3 found unresponsive: Jul 9, 2024
Date resident #3 passed away: Jul 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Funderburg | Administrator | Facility administrator met with investigator and provided information |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 220
Deficiencies: 1
Sep 26, 2024
Visit Reason
The visit was an unannounced case management inspection regarding an incident report submitted on 2024-09-11 about a resident who eloped from the memory care unit on 2024-08-31.
Findings
The licensee failed to ensure that resident #1 did not elope from the facility, posing an immediate risk to the health, safety, and personal rights of the persons in care. Staff were unaware that the resident had left the memory care unit, and corrective actions including staff training and warnings were implemented.
Complaint Details
The visit was triggered by a complaint/incident report regarding resident #1 eloping from the memory care unit on 2024-08-31. The complaint was substantiated as deficiencies were cited.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Based on documents reviewed and interviews conducted the licensee did not ensure R1 did not elope from the facility which poses an immediate risk to the health, safety, and personal rights of the persons in care. | Type A |
Report Facts
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met with Licensing Program Analyst during the visit and involved in the exit interview |
| Mary G Flores | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Tony Vasallo | Supervisor | Named as supervisor in the deficiency report |
Inspection Report
Complaint Investigation
Census: 131
Capacity: 220
Deficiencies: 0
Sep 26, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations including failure to prevent a resident's fracture, hazardous conditions causing injuries, facility disrepair, failure to follow physician's orders, and interference with resident's sleep.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations. The facility was found to be safe with no hazardous conditions, the showers and A/C were in working condition, physician's orders were followed appropriately, and staff responded to resident concerns about sleep disturbances.
Complaint Details
The complaint investigation was unsubstantiated for all allegations including failure to prevent resident injury, hazardous conditions, facility disrepair, failure to follow physician's orders, and interference with resident's sleep.
Report Facts
Facility capacity: 220
Resident census: 131
Number of residents interviewed: 10
Number of staff interviewed: 6
Number of resident rooms toured: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit |
| Stephanie Funderburg | Administrator | Facility administrator met during investigation and exit interview |
| Mario Henriquez | Maintenance Director | Accompanied Licensing Program Analyst during facility tour |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 131
Capacity: 220
Deficiencies: 1
Sep 26, 2024
Visit Reason
An unannounced annual continuation inspection visit was conducted to evaluate compliance with various regulatory domains including infection control, staffing, medical care, and resident rights.
Findings
The inspection found a deficiency related to medication labeling where prescribed medication for resident #3 did not have labels, posing a potential health and safety risk. Other domains such as infection control, staffing, and disaster preparedness were reviewed without noted deficiencies.
Deficiencies (1)
| Description |
|---|
| Prescribed medication for resident #3 was observed without labels, violating medication labeling requirements. |
Report Facts
Staff files reviewed: 8
Residents medication reviewed: 7
Deficiency POC due date: Oct 3, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met during inspection and involved in exit interview |
| Mary G Flores | Licensing Evaluator | Conducted the inspection and signed the report |
| Tony Vasallo | Supervisor | Supervisor overseeing the inspection process |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 220
Deficiencies: 0
Sep 6, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that staff were not preventing the spread of COVID-19.
Findings
The investigation included interviews with staff and residents, review of documents, and a facility tour. Although some staff and residents were observed without masks, the recent rescission of the mask order in Pasadena was noted. The allegation was found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint alleged that staff were not preventing the spread of COVID-19. The allegation was unsubstantiated after investigation, with 10 of 12 residents and 5 of 5 staff denying the allegation. The COVID outbreak was not reported per the 24-hour reporting requirement, which will be addressed in a separate case management report.
Report Facts
Residents interviewed: 12
Staff interviewed: 5
Residents denying allegation: 10
Staff denying allegation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Executive Director | Met with Licensing Program Analyst during investigation and involved in facility tour |
| Tena Herrera | Licensing Program Analyst | Conducted the complaint investigation visit |
| David Sicairos | Licensing Program Manager | Named as Licensing Program Manager on report |
| Ann-Marie Boersma | Wellness Director | Accompanied Licensing Program Analyst during facility tour |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 220
Deficiencies: 1
Sep 6, 2024
Visit Reason
The visit was conducted as a case management investigation related to complaint control #28-AS-20240905092935 concerning the facility's failure to report a Covid-19 outbreak within the required 24-hour timeframe.
Findings
The facility failed to notify the Department of the Covid-19 outbreak within the 24-hour reporting requirement, as multiple residents tested positive several days before the report was sent. This deficiency was documented and cited under regulation LIC809-D.
Complaint Details
Complaint control #28-AS-20240905092935 was investigated and substantiated based on the facility's failure to report the Covid-19 outbreak within the required timeframe.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report epidemic outbreak to licensing agency within 24 hours as required, despite multiple residents testing positive for Covid-19 five days prior to reporting. | Type B |
Report Facts
Residents tested positive for Covid-19: 6
Deficiency count: 1
Plan of Correction Due Date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met with Licensing Program Analyst during the complaint investigation |
| Tena Herrera | Licensing Program Analyst | Conducted the case management visit and complaint investigation |
| David Sicairos | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 220
Deficiencies: 1
Sep 4, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that staff handled a resident in a rough manner.
Findings
The investigation substantiated that staff member S1 assisted resident R2 aggressively, causing R2 to scream in pain due to rough handling while placing the resident's leg in the wheelchair footrest. S1 was suspended and subsequently terminated for suspected abuse. No physical injuries were caused to the resident.
Complaint Details
The complaint was substantiated. The allegation was that staff handled a resident in a rough manner. Evidence included incident reports, staff and resident interviews, and internal investigation. Staff member S1 was suspended and terminated following the investigation. No physical injuries were found. The Pasadena Police Department conducted a visit and filed a report.
Deficiencies (1)
| Description |
|---|
| Deficiency on personal rights due to suspected abuse occurred to residents in care at the facility. |
Report Facts
Facility capacity: 220
Census: 127
Incident report date: Aug 6, 2024
Complaint received date: Aug 27, 2024
Suspension and termination date: Aug 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 127
Capacity: 220
Deficiencies: 1
Aug 27, 2024
Visit Reason
An unannounced annual inspection visit was conducted using the CARE inspection tool to evaluate compliance with licensing regulations at the facility.
Findings
The facility was found to be in good repair with sufficient food supplies and proper safety measures in place. However, a deficiency was noted regarding the storage of a cleaning solution accessible to residents in a memory care unit room, posing a safety risk.
Deficiencies (1)
| Description |
|---|
| Cleaning solution was observed under bathroom's sink in room #150 in the memory care unit, making it accessible to residents and posing an immediate health and safety risk. |
Report Facts
Food supply duration: 2
Food supply duration: 7
Residents reviewed: 7
Residents interviewed: 7
Staff interviewed: 6
Rooms observed: 12
Water temperature range: 108
Water temperature range: 117
Fire extinguisher last checked: Sep 7, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met with Licensing Program Analyst during inspection |
| Mario Henriquez | Maintenance Director | Conducted facility tour with Licensing Program Analyst |
| Mary G Flores | Licensing Evaluator | Conducted inspection and authored report |
| Tony Vasallo | Supervisor | Supervised licensing evaluation |
Inspection Report
Complaint Investigation
Census: 126
Capacity: 220
Deficiencies: 1
Aug 22, 2024
Visit Reason
The visit was an unannounced case management inspection triggered by incident reports submitted on 08/06/2024 and 08/08/2024 regarding allegations of physical abuse by staff towards residents and a choking incident requiring Heimlich maneuver assistance.
Findings
The investigation substantiated physical abuse by staff member S1 towards two residents in the memory care unit, resulting in a deficiency citation. No injuries were caused, but the staff member was suspended and terminated. A separate choking incident was handled promptly with no deficiencies noted.
Complaint Details
The complaint investigation was substantiated regarding physical abuse by staff member S1 towards two residents (R1 and R2) in the memory care unit. The facility conducted an internal investigation, suspended, and terminated the staff member. Police department conducted a visit and filed report #PA24-61517.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff treated residents with dignity and respect, resulting in physical abuse towards two residents in the memory care unit. | Type A |
Report Facts
Incident report dates: Incident reports submitted on 08/06/2024 and 08/08/2024
Incident dates: Physical abuse incidents occurred on 07/26/2024 and 07/29/2024; choking incident on 08/04/2024
Plan of Correction Due Date: 08/23/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met with Licensing Program Analyst during inspection and exit interview |
| Mary G Flores | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Tony Vasallo | Supervisor | Supervisor named on the report |
Inspection Report
Complaint Investigation
Capacity: 220
Deficiencies: 1
Mar 19, 2024
Visit Reason
The inspection was an unannounced case management visit triggered by an incident report submitted on 2024-03-07 regarding a resident who eloped the facility on 2024-03-04.
Findings
The facility failed to prevent resident #1 from eloping through an emergency exit door despite the delay egress system working. The resident sustained a minor head laceration and was hospitalized briefly. Deficiencies were cited related to insufficient staffing to meet resident needs and failure to prevent elopement, posing immediate risk to resident safety.
Complaint Details
The visit was complaint-related due to an incident where resident #1 eloped the facility by exiting through an emergency exit door and climbing over a parking gate. The incident was substantiated by video footage and staff interviews.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87411 Personnel Requirements - Facility personnel were not sufficient in numbers and competent to meet resident needs, failing to prevent resident elopement. | Type A |
Report Facts
Facility capacity: 220
Incident date: Mar 4, 2024
Incident report submission date: Mar 7, 2024
Plan of Correction due date: Mar 20, 2024
Laceration size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met with Licensing Program Analyst during inspection and involved in incident interviews |
| Tony Vasallo | Supervisor | Named as supervisor in report |
| Mary G Flores | Licensing Evaluator | Conducted inspection and signed report |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 220
Deficiencies: 1
Mar 4, 2024
Visit Reason
The visit was an unannounced case management inspection conducted in response to an incident report submitted on 2024-02-21 regarding a resident elopement from the memory care unit.
Findings
The inspection found that a resident with dementia eloped from the memory care unit by climbing over a fenced door. The facility had a plan of care for the resident and was in the process of hiring additional staff. However, an obstruction was noted in the passageway leading to the exit door from the courtyard, resulting in a cited deficiency.
Complaint Details
The visit was triggered by a complaint incident report of a resident elopement from the memory care unit on 2024-02-21. The complaint was substantiated by observation and review of video surveillance.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure that all passageways were free of obstruction, posing a potential risk to health, safety, or personal rights of persons in care. | Type B |
Report Facts
Residents in memory care unit: 29
Staff on shift: 3
Plan of Correction due date: Mar 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Funderburg | Administrator | Met with Licensing Program Analyst during visit and named in relation to incident and corrective actions |
| Mary G Flores | Licensing Evaluator | Conducted the inspection and signed the report |
| Tony Vasallo | Supervisor | Named as supervisor in the report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 220
Deficiencies: 1
Dec 21, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation in response to an allegation that staff unlawfully evicted a resident.
Findings
The investigation found that resident #1 was not given the required 30 days written eviction notice before leaving the facility. It was determined that resident #1 required a higher level of care not initially identified at admission, and the facility did not feel the resident should return after hospital discharge. The allegation was substantiated and deficiencies were cited.
Complaint Details
The complaint alleged that staff unlawfully evicted resident #1. The allegation was substantiated based on record review and interviews. Resident #1 moved in on 11/21/2023 and left on 12/4/2023 without receiving a 30-day eviction notice. The facility determined resident #1 required a higher level of care and should not return after hospital discharge.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide resident #1 with 30 days written eviction notice as required by eviction procedures. | Type B |
Report Facts
Facility capacity: 220
Census: 94
Plan of Correction due date: Dec 28, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation |
| Stephanie Funderburg | Administrator who assisted with the investigation and exit interview | |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Capacity: 220
Deficiencies: 0
Dec 8, 2023
Visit Reason
The visit was an unannounced case management follow-up to an incident report submitted on 2023-12-07 regarding a resident who left the facility unattended.
Findings
The Licensing Program Analyst found that the resident had left the facility unattended twice as allowed by a physician's report, but due to concerns about the resident's dementia diagnosis and decision-making capacity, the facility will obtain a reassessment and submit updated documentation by 2023-12-18. No deficiencies were noted during the visit.
Report Facts
Facility capacity: 220
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the unannounced case management visit |
| Stephanie Funderburg | Executive Director | Met with Licensing Program Analyst during the visit |
| Erin Mahoney | Administrator | Facility administrator mentioned in the report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 220
Deficiencies: 0
Dec 5, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not prevent a resident from being sexually abused while in care.
Findings
The investigation found that a male resident allegedly inappropriately touched a female resident in an elevator. Surveillance video and interviews were reviewed, but due to cognitive impairments and lack of sufficient evidence, the allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff failed to prevent sexual abuse of a resident. The investigation included interviews with residents and staff, review of surveillance footage, and contact with the police department. The allegation was unsubstantiated due to insufficient evidence.
Report Facts
Capacity: 220
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Stephanie Funderburg | Administrator | Facility administrator met during the investigation and exit interview |
| Brianna Goodlett | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 220
Deficiencies: 2
Oct 19, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 03/28/2023 regarding inadequate care and supervision, staff blocking doorways to prevent residents from leaving, and other resident care concerns at Astoria Park Senior Living Facility.
Findings
The investigation substantiated that staff did not provide adequate care and supervision, including residents exiting the memory care unit unattended and a blocked exit door with a non-functioning egress system. Other allegations such as staff leaving residents soiled, use of inappropriate language, and staff behavior posing risk were found unsubstantiated based on interviews and observations.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not provide adequate care and supervision, including residents exiting the memory care unit unattended and blocked exit doors. Other allegations regarding staff leaving residents soiled, inappropriate language, and risky staff behavior were unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents who continue to indicate a desire to leave the facility following redirection are permitted to do so with staff supervision, specifically residents exiting the memory care unit unattended. | Type A |
| Failure to maintain exit door by room #129 with a working egress system at all times; door was blocked with a sliding wood board and egress system was not working. | Type B |
Report Facts
Capacity: 220
Census: 97
Deficiencies cited: 2
Plan of Correction Due Dates: 10
Plan of Correction Due Dates: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation report |
| Erin Mahoney | Administrator | Met during inspection and exit interview; involved in findings |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 220
Deficiencies: 2
Oct 19, 2023
Visit Reason
An unannounced case management visit was conducted during a complaint investigation related to complaint #28-AS-20230328095738.
Findings
Two deficiencies were noted: failure to report an incident involving a resident leaving the facility unattended within 7 days, and failure to provide an annual medical assessment and care plan for a dementia resident who eloped.
Complaint Details
Complaint #28-AS-20230328095738 was investigated, with findings delivered on 10/19/23. The complaint involved a resident leaving the facility unattended and lack of proper reporting and care planning.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an incident on 3/24/23 involving a resident found outside the facility within 7 days as required by regulations. | Type B |
| Failure to obtain an annual medical assessment and develop a care plan for a dementia resident who left the facility unattended. | Type B |
Report Facts
Deficiencies cited: 2
Capacity: 220
Census: 97
Plan of Correction Due Date: Oct 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Evaluator | Conducted the complaint investigation and delivered findings |
| Erin Mahoney | Administrator | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Tony Vasallo | Supervisor | Named as supervisor in the report |
Inspection Report
Complaint Investigation
Capacity: 220
Deficiencies: 0
Oct 5, 2023
Visit Reason
The visit was an unannounced case management inspection triggered by an incident report submitted on 2023-10-02 regarding a resident who reportedly jumped from a bedroom window.
Findings
The investigation found that Resident #1 jumped from a window but had no documented history or recent indications of suicidal tendencies. Staff responded promptly, and the resident was hospitalized. No deficiencies were noted during the visit.
Complaint Details
The visit was conducted due to an incident report alleging Resident #1 jumped from a window. The complaint was investigated through staff interviews, file review, and observation. No substantiated deficiencies or violations were found.
Report Facts
Facility capacity: 220
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Goodlett | Administrator | Met with Licensing Program Analyst during the visit and was informed of the incident |
| Mary Flores | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Erin Mahoney | Executive Director | Provided additional information over the phone regarding the incident |
Inspection Report
Annual Inspection
Census: 95
Capacity: 220
Deficiencies: 10
Sep 21, 2023
Visit Reason
Licensing Program Analyst Mary Flores conducted an unannounced annual visit at the facility using the CARE tool to evaluate compliance with regulations and licensing requirements.
Findings
The inspection identified multiple deficiencies including unsecured disinfectant sprays in the dementia unit, lack of TB clearance and health screenings for some staff, expired CPR/First Aid training, maintenance issues such as a clogged toilet and water damage, obstructed passageways, and an outdated emergency disaster plan. Plans of correction were required for all deficiencies.
Severity Breakdown
Type A: 1
Type B: 9
Deficiencies (10)
| Description | Severity |
|---|---|
| Disinfectant sprays observed in dementia unit kitchenette cabinet without a lock, posing immediate health and safety risk. | Type A |
| Staff member S4 does not have a TB clearance on file. | Type B |
| Two staff members (S4 and S5) do not have health screenings on file. | Type B |
| Toilet in room #149 was clogged and overflowed. | Type B |
| Dementia bathroom faucet sink in dining room not working; activity room refrigerator dirty; ceiling by family lounge with water damage and crack; screen door on floor in dementia courtyard. | Type B |
| Five out of five staff files reviewed did not have current CPR/First Aid training; administrator's CPR/First Aid expired. | Type B |
| Emergency disaster plan LIC 610E(10/03) outdated and does not meet current requirements. | Type B |
| Resident #3 does not have an updated physician's report; last dated 3/15/22. | Type B |
| Passageways on first floor obstructed by bench and chairs near dementia courtyard and outside room #119. | Type B |
| Administrator Brianna Goodlett does not have a current administrator certificate; department not notified of change to new administrator Erin Mahoney. | Type B |
Report Facts
Residents medication reviewed: 9
Resident files reviewed: 5
Staff files reviewed: 5
Food supply duration: 2
Food supply duration: 7
Fire extinguisher last checked: Sep 7, 2023
Last fire emergency drill: May 24, 2023
Water temperature range: 107.2-117.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Goodlett | Administrator | Named in findings related to expired CPR/First Aid training, lack of renewal of administrator certificate, and staff training plans |
| Gina Lopez | Business Manager | Met with Licensing Program Analyst during inspection and involved in facility tour and exit interview |
| Erin Mahoney | Executive Director / New Administrator | To be appointed as new administrator; department not notified of change |
| Mary G Flores | Licensing Program Analyst | Conducted the inspection and authored the report |
| Tony Vasallo | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 220
Deficiencies: 0
May 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was hit with an object by an unknown perpetrator resulting in a fracture.
Findings
The investigation found that although the resident did sustain a sternal fracture and initially identified a perpetrator, there was no preponderance of evidence to support that anyone inflicted the injury. The allegations were therefore unsubstantiated.
Complaint Details
The complaint alleged that a resident was assaulted by another resident resulting in a fracture. The investigation included interviews with staff and review of video footage, hospital and police reports. The evidence did not substantiate the allegation.
Report Facts
Facility capacity: 220
Resident census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Brian Slatic | Investigator | Conducted interviews with staff and resident during investigation |
| Brianna Goodlett | Administrator | Facility administrator who provided information and reviewed video footage |
Inspection Report
Follow-Up
Census: 80
Capacity: 220
Deficiencies: 0
Oct 17, 2022
Visit Reason
The visit was a case management follow-up to verify corrections needed from a pre-licensing visit conducted on 2022-09-12.
Findings
The facility corrected previously noted issues including fixing a loose outlet cover plate, repairing a hole in a wall, maintaining water temperatures within required ranges, and ensuring skid strips were present in bathrooms. Medication storage issues were resolved with updated physician documentation.
Report Facts
Water temperature range: 110.3 to 117.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Flores | Licensing Program Analyst | Conducted the case management visit and inspection. |
| Brianna Goodlett | Applicant's Representative | Met with Licensing Program Analyst and participated in exit interview. |
| Gina Lopez | Staff | Accompanied Licensing Program Analyst during the tour and observation. |
Inspection Report
Original Licensing
Census: 83
Capacity: 220
Deficiencies: 5
Sep 12, 2022
Visit Reason
An announced pre-licensing visit was conducted to evaluate the facility for licensing purposes and ensure compliance with regulations.
Findings
The facility was generally observed to be in good repair with clean and sanitized areas, sufficient food supplies, and proper infection control protocols. However, several deficiencies were noted including loose outlet cover plates, holes in walls, water temperatures not maintained within required range, missing skid strips/mats in some bathrooms, and medication stored in resident rooms.
Deficiencies (5)
| Description |
|---|
| Loose outlet cover plate in room #145 |
| Hole in the wall in room #103 |
| Water temperature not maintained between 105 and 120 degrees F in multiple rooms (#160, 159, 156, 153, 152, 150, 149, 145, 141, 139) |
| Missing skid strips/mats in bathrooms of rooms #141 and #153 |
| Medication stored in resident rooms #155 and #256 |
Report Facts
Capacity: 220
Census: 83
Food supply duration: 2
Food supply duration: 7
Water temperature range: 101.6
Water temperature range: 120
Fire inspection clearance date: Jul 11, 2022
Resident files reviewed: 9
Staff files reviewed: 7
PPE supply duration: 30
Correction timeframe: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brianna Goodlet | Applicant's Contact Person | Met with LPAs during inspection and exit interview |
| Brandon Collins | Vice President | Accompanied LPAs during facility tour |
| Jennifer Siegel | Regional Wellness Director | Accompanied LPAs during facility tour |
| Mary G Flores | Licensing Evaluator | Conducted inspection and signed report |
| Stefanie Coronel | Supervisor | Oversaw inspection process |
Inspection Report
Original Licensing
Census: 75
Capacity: 220
Deficiencies: 0
Jul 27, 2022
Visit Reason
The visit was conducted as part of a Change of Ownership (CHOW) application process involving a telephone call with the Community Care Licensing analyst to verify applicant and administrator identity and confirm understanding of licensing requirements.
Findings
The applicant and administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, staff qualifications, program policies, grievance procedures, and physical plant requirements. Technical assistance was provided regarding application documents and certifications.
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