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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605216
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:06:46 PM


Document Has Been Signed on 01/11/2024 03:06 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:PASADENA MANSIONFACILITY NUMBER:
197605216
ADMINISTRATOR:EWA NYCZAKFACILITY TYPE:
740
ADDRESS:779 S. PASADENA AVENUETELEPHONE:
(626) 356-7575
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY:6CENSUS: 3DATE:
01/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Ewa Nyczak - AdministratorTIME COMPLETED:
03:21 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit regarding an incident reports that were not reported to the Community Care Licensing Department. LPA met with Ewa Nyczak (Administrator) and explained the reason for the visit.

On 01/11/2024, during a complaint investigation (complaint control number: 28-AS-20240105092231) LPA Mora found out that the facility failed to report Resident 1 (R1) fall, hospitalization and death back in September 2023. During the visit, the Administrator could not remember the date of the fall and hospitalization. The death date is 09/18/2023.

The deficiency cited is documented on the LIC809-D. Exit interview held and a copy of the report and appeal was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/11/2024 03:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: PASADENA MANSION
FACILITY NUMBER: 197605216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2024
Section Cited
CCR
87211(a)(1)(A)(D)

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Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Administrator is to ensure that Title 22 Section 87211 regulations are met at all times. Administrator will submit incident reports and death report for Resident 1 (R1) fall, hospitalization and death to Community Care Licensing Division (CCLD) by 01/11/2024 5pm.
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This regulation has not been met as evidenced by:

Based on interviews and records review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The facility failed to report an incident reports regarding R1 fall, hospitalization and death to CCLD.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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