197603952-8-5-2025-28-AS-RORN-DLCPEV-20250909111543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603952
Report Date: 08/05/2025
Date Signed: 08/05/2025 02:35:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
05/23/2025 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250523163423

FACILITY NAME:	PROSPECT MANOR		FACILITY NUMBER:	197603952
ADMINISTRATOR:	LYDIA PABION		FACILITY TYPE:	740
ADDRESS:	800 PROSPECT AVE		TELEPHONE:	(626) 799-1141
CITY:	SOUTH PASADENA	STATE: CA	ZIP CODE:	91030
CAPACITY:	99	CENSUS: 50	DATE:	08/05/2025
		UNANNOUNCED	TIME BEGAN:	02:17 PM
MET WITH:	Lydia Pabion - Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility staff did not provide adequate supervision resulting in a resident being attacked by another resident.
Facility staff did not notify authorized representative of incident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegations. LPA met Lydia Pabion with and explained the reason for the visit.

The investigation consisted of the following: LPA requested staff/resident rosters. On 5/27/25 LPA Flores interviewed the administrator, 3 staff, 5 residents, reviewed file for resident #1-#2(R1-R2) and requested copies of medical assessment, needs and care plan, admission agreement, information and emergency information sheet, power of attorney, and incident reports. On 7/22/25, 7/28/25, and 7/31/25 LPA attempted to contact South Pasadena Police officer. On 7/31/25 LPA interviewed 1 staff over the phone. On 8/5/25 LPA delivered findings.

The investigation revealed the following: Regarding allegation: Facility staff did not provide adequate supervision resulting in a resident being attacked by another resident. It is alleged that on 5/7/25, R1 was attacked by roommate resulting in an injury. (CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250523163423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PROSPECT MANOR	FACILITY NUMBER: 197603952
	VISIT DATE: 08/05/2025

NARRATIVE

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Interviews conducted with residents revealed 4 out of 5 residents stated not have observed R2 having aggressive behaviors, hearing an argument, loud noises, or being hurt by R2 at the facility. 1 out of 5 residents stated R2 hit resident with an open hand in the face seven times the evening of 5/7/25. Interviews with staff determined staff did not observe or hear loud noises that indicate the incident was happening. Staff stated that on 5/8/25 LVN noted the bruise around the eye when providing eye drops in the morning. Per staff, R2 has not shown aggressive behaviors in the last six months, other than the one incident they observed in the dining room on 6/11/25. Documents reviewed revealed; incident report dated 5/8/25 notes R1 was observed with a bruise in the eye and R1 stated that it was due to R2 hitting R1. R1 was provided with first aid assistance, R1’s responsible party was notified, and R2 was transferred to a different room. Incident report dated: 6/11/25 notes R2 was walking behind R1 in the dining room and pulled R1’s hair causing R1 to fall. The administrator contacted South Pasadena Police Department and police report was created. R2’s physician’s report does not note aggressive behaviors. Although R1 had a bruise on 5/8/25 it is unsure if R2 caused the bruise, and the incident on 6/11/25 did happen. The facility took action once the first incident and moved R2 to a different room. During the second incident Administrator contacted South Pasadena Police Department and sought care for R1 and R2. Therefore, the allegations is unsubstantiated.

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: Facility staff did not notify authorized representative of incident. It is alleged facility staff did not notified R1’s responsible party regarding incident that occurred on 5/7/25. Interviews with residents revealed facility staff notified their responsible party when necessary. Interviews with staff revealed Administrator or LVN notify responsible party when incidents take place. Per administrator, on 5/8/25 administrator contacted R1’s responsible party phone number at least three times and was unable to leave a voice message. Interview with R1’s responsible party revealed upon visit administrator had stated to them that they had attempted to notify them of the bruise but had not been able to reach them. Incident report dated 5/8/25 notes administrator notified responsible party. Although the administrator may not have reach R1’s responsible party. It was noted on incident report dated 5/8/25 that they contacted the responsible party. Therefore, this allegation is unsubstantiated.
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 Lydia Pabion and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025

LIC9099 (FAS) - (06/04)

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