Prospect Manor

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Jose De Leon and explained the reason for the visit. The investigation consisted of the following: On 8/5/25 LPA Flores conducted an initial complaint investigation visit, interviewed administrator and nurse and collected the following documents for Resident #1’s (R1) file and requested copies of physician’s report, needs and care plan, identification and emergency sheet, admission agreement, hospital discharge documents, medication sheets, and home health plan. On 8/28/25 LPA Flores conducted an unannounced subsequent complaint visit and interviewed 5 residents and 5 staff. On 9/18/25 LPA Flores contacted Home Health Agency. On 11/24/25 LPA Flores contacted R1 over the phone. On 12/5/25 LPA Flores delivered findings. (CONTINUED ON LIC 9099C) UnsubstantiatedRead the full finding— CDSS inspection report, December 5, 2025 · control 28-AS-20250728111411

*This report is a corrected version of report dated 8/5/25 to change finding and substantiated one of the allegations and add additional information.* Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Janice Somera 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. On 8/7/25 LPA interviewed South Pasadena Police Department officer. On 8/11/25 LPA Flores interviewed R1's rRead the full finding— CDSS inspection report, August 30, 2025 · control 28-AS-20250523163423

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced and met with the administrator, Lydia Pabion. The purpose of the visit was explained. LPA obtained a copy of the staff roster, resident roster, and documents on Resident #1 (R1). LPA interviewed the administrator, 3 Staff, and 5 Residents. R1 was not available for the interview today. The investigation revealed the following: Allegation - Lack of staff supervision resulting in resident eloping from the facility. It is alleged that Resident #1 (R1) was found by law enforcement and was in the hospital for dehydration. According to staff interviews, R1 was not in the facility around 7 pm on 8/5/25. SubstantiatedRead the full finding— CDSS inspection report, August 15, 2025 · control 28-AS-20250808152943

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. (Read the full finding— CDSS inspection report, August 5, 2025 · control 28-AS-20250523163423

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Lydia Pabion and explained the reason of the visit. The investigation consisted of the following: On 10/15/24 LPA conducted and initial complaint investigation visit. During the initial visit LPA requested staff/resident roster, resident #1(R1)’s physician’s report dated: 8/21/23, admission agreement, pre-appraisal, needs and care plan, medication sheet, incident report. LPA interviewed Resident #1-#3(R1-R3) and 5 staff. On 10/18/24 LPA interviewed R1’s Assisted Living Waiver (ALW) case manager over the phone and obtained documents. On 10/21/24 LPA interviewed R1’s Power of Attorney (POA) over the phone. On 10/29/24 LPA Flores delivered findings for the above allegation. (CONTINUED ON LIC 9099C) SubstantiatedRead the full finding— CDSS inspection report, October 29, 2024 · control 28-AS-20241011081106

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent visit to continue investigation and deliver findings for the above mentioned allegation. LPA met with Administrator Lydia Pabion and discussed purpose of visit. LPA interviewed Five (5) residents and one (1) additional staff S#1 during this visit. LPA took tour of facility and did not observed any health and safety Hazards. On 09/25/2023; LPA conducted a health and safety check and took a tour of the physical plant including the common areas, kitchen, dining room, medications room, and five (5) resident rooms. LPA measured the water temperature, and it was within 105-120 degrees F. LPA observed that there was at least a 7-day supply of non-perishable foods, and a 2-day supply of perishable foods and medications were centrally stored and locked. The facility was clean and in good repair and there were no observable signs of neglect, abuse or other immediate health and safety threats. (Continue on 9099C) SubstantiatedRead the full finding— CDSS inspection report, October 10, 2024 · control 28-AS-20230922133247

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Lydia Pabion and explain the reason of the visit. The investigation consisted of the following: LPA requested copies of staff/resident roster, reviewed resident #1’s file, and requested copies of identification and emergency sheet, physician’s report, admission agreement, notice to pay rent, receipts for payment from January 2023 – February 2024, to the facility. LPA interviewed 5 residents and 5 staff. The investigation revealed the following: Regarding allegation Illegal eviction it is alleged R1 was given an eviction notice on 2/23/24, for lack of rent payment, per complainant R1 has paid the rent in full every month. Interviews conducted with administrator and licensee revealed R1 has not been given an eviction notice yet. (CONTINUED ON LIC 9099C) UnsubstantiatedRead the full finding— CDSS inspection report, March 4, 2024 · control 28-AS-20240226102810

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to investigate the above allegations. LPA met with Lydia Pabion, Administrator and explained the reason for the visit. The initial complaint visit was conducted on 12/28/2023. During the initial and subsequent complaint visits, the investigation consisted of the following: LPA conducted a physical plant tour of the facility, interviewed Resident #1- Resident #11 (R1- R11) and Staff #1- Staff #7 (S1- S7) altogether. LPA unable to interview Staff #8 (S8) who was not on duty. LPA also attempted to interview Resident #12 (refused to speak to LPA/on Hospice care) and Resident #13 (R13) - Resident #14 (R14) but unsuccessful as they are both non verbal. LPA obtained copies of the Resident and Staff Rosters, reviewed Residents #1-#2 (R1-R2's) file documents such as; Face Sheet, Needs and Services Plan, Physician's Report LIC 602, and Progress notes. Additionally, (5) Staff files, (3) additional Resident filesRead the full finding— CDSS inspection report, February 9, 2024 · control 28-AS-20231222091841

*This report supersedes report dated 11/07/2023 due to findings changed for 1 allegation* Licensing Program Analysts (LPAs) Mora and Vaid conducted an unannounced complaint visit regarding the above allegations. LPAs met with Lydia Pabion (Administrator) and explained the reason for the visit. The investigation consisted of the following: LPAs obtained copies of staff and resident rosters, reviewed pest control reports dating back to June 2023, and interviewed Administrator, Staff 1 - Staff 6 (S1 - S6) and Resident 1 - Resident 7 (R1 - R7). LPAs also toured 3 resident rooms and the facility's TV room. The investigation revealed the following: regarding the allegation "staff are sleeping at the facility", it is alleged that staff are sleeping at the facility during their shifts. Administrator stated 2 months ago she reviewed her camera footage and noticed a graveyard staff sleeping on job. She confronted the staff and the staff resigned on 09/14/23. Administrator stated this was a one tRead the full finding— CDSS inspection report, January 9, 2024 · control 28-AS-20231030095916

Licensing Program Analysts (LPAs) Mora and Vaid conducted an unannounced complaint visit regarding the above allegations. LPAs met with Lydia Pabion (Administrator) and explained the reason for the visit. The investigation consisted of the following: LPAs obtained copies of staff and resident rosters, reviewed pest control reports dating back to June 2023, and interviewed Administrator, Staff 1 - Staff 6 (S1 - S6) and Resident 1 - Resident 7 (R1 - R7). LPAs also toured 3 resident rooms and the facility's TV room. The investigation revealed the following: regarding the allegation "facility has bedbugs", it is alleged that there are bedbugs in rooms 201, 205, 227 and the facility's TV room. Administrator denied the allegation and stated no bedbugs complaints have been brought to her attention. Staff interviewed could not corroborate the allegations. Residents in rooms 201 and 227 denied having bedbugs and resident in room 205 was out in the community and not available for an interview. (Read the full finding— CDSS inspection report, November 7, 2023 · control 28-AS-20231030095916

Licensing Program Analyst (LPA) Flores conducted a subsequent complaint visit. LPA met with Lydia Pabion and explained the reason for the visit. The purpose of today's visit is to deliver findings for LPA Irra who was assigned this complaint. On 07/15/21, Licensing Program Analyst (LPA) Spencer conducted a Health and Safety check visit in response to the above personal rights allegation. LPA met with administrator Lydia Pabion. During this visit, LPA Spencer conducted a health and safety check and took a tour of the physical plant including the common areas, kitchen, dining room, medications room, and five (5) resident rooms. The facility was clean and in good repair and there were no observable signs of neglect, abuse or other immediate health and safety threats. LPA Spencer obtained a copy of staff roster, resident roster, and for three (3) specified residents: resident face sheet, MAR log, physician's report, and appraisal needs & services plan. (CONTINUED ON LIC 9099C) SubstantiateRead the full finding— CDSS inspection report, June 6, 2023 · control 28-AS-20210714145302

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Lydia Pabion Administrator and explained the reason for the visit. The investigation consisted of the following: LPA Flores requested a copy of resident/staff roster, conducted a tour of facility's resident rooms #103,108,112,117,224,220,211,204, a total of 12 thermostats were observed throughout the facility's hallways next to the following rooms #104,107,111,119,232,227,220,216,212,208,201 all set up and read at 72 degrees F. except for thermostat next to room #107 read at 69 degrees F and set up at 72 degrees F., and thermostat next to room# 232 which was set up at 74 and read at 72 degrees F. Interviewed resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5) and staff #1(S1),#2(S2),#3(S3),#4(S4) and #5(S5). LPA Flores reviewed activity calendar for the month of January 2023, S3 duties and responsibilities sheets. (CONTINUED ON LIC 9099C) URead the full finding— CDSS inspection report, January 30, 2023 · control 28-AS-20230124121154