197605216-11-30-2023-28-AS-MGFS-CY3SEY-20231130124931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197605216
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:49:53 PM

Document Has Been Signed on 11/30/2023 12:49 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 MANSION		FACILITY NUMBER:	197605216
ADMINISTRATOR:	EWA NYCZAK		FACILITY TYPE:	740
ADDRESS:	779 S. PASADENA AVENUE		TELEPHONE:	(626) 356-7575
CITY:	PASADENA	STATE: CA	ZIP CODE:	91105
CAPACITY:	6	CENSUS: 3	DATE:	11/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:37 AM
MET WITH:	Larry Ho - Caregiver		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Larry Ho and explained the reason for the visit. The facility is licensed to serve 3 ambulatory and 3 non-ambulatory residents age 60 and above. Non-ambulatory in ground bedrooms only. Facility is a two story residential home consists of (3) resident bedrooms, (1) staff/guest bathroom, 1 full bathroom, a living room, dining room, office area, kitchen, laundry area in the lower floor, (3) resident bedrooms, a sun room(storage), (1) resident bathroom, (1) staff bedroom and bathroom in the second floor. Backyard, a side garden that includes pergola table and chairs, detached garage for storage purposes, and a front yard. LPA toured the facility with Larry Ho and observed the following: Facility is in good repair indoor and outdoor, passages are clear of obstructions. Living room, office, front entrance, and dining are clean with sufficient furniture and activities. Bug killing spray was observed next to sofa by the entrance to the living room. Kitchen area is clean, pantry and refrigerator was observed with sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Staff medication container was observed in the kitchen's dining table, an apothecary cabinet was observed with residents medication to be dispensed accessible to the residents. Laundry area is clean, laundry detergent and bleach is accessible to the residents in a cabinet next to the washer. Each residents room has sufficient lighting, furniture, and bedding supplies. There are 2 residents on hospice with full bed rails with request per hospice on file, and 1 resident on home health care with a half bed rail request on file per physician. Each bathroom is clean and in working condition with grab bars and skid mats, water temperature was tested in each bathroom and tested between 107.7-109.5 degrees F. which is within the required 105-120 degrees F. Smoke/Carbon monoxide detectors were tested throughout the facility. Fire extinguishers were observed last checked on 3/13/21. Side yard is clean and has sitting area. No large bodies of water were observed. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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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Document Has Been Signed on 11/30/2023 12:49 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in bug killer spray and laundry detergent are accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/01/2023
	Plan of Correction
1 2 3 4	Administrator will provide a lock or unaccessible area to store cleaning solutions and poisons and provide training to staff regarding section 87309 and safety concerns of accessibility of the above to dementia residents, and will submit a copy of training topic, sign in log, and duration of training to the department by POC due date 12/1/23.

Type A

Section Cited

CCR

87309(b)

Storage Space

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in staff's medication was observed on top of kitchen's dining table, an apothecary accessible to the residents was observed with varios medication which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/01/2023
	Plan of Correction
1 2 3 4	Administrator and staff removed the medications during the visit. Administrator will provided staff training on the importance of ensuring medication are kept unaccessible to the residents at all times and will submit to the department a copy of training topic, duration, and sign in log by POC due date 12/1/23.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/30/2023 12:49 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(5)(D)

Incidental Medical and Dental Care Services

(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the licensee did not comply with the section cited above in R3's medication (pill) is put in the residents ensure for R3 to take without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/01/2023
	Plan of Correction
1 2 3 4	Administrator will obtain a physician's request to crush or mix medication for R3, will keep it on file, and submit a copy to the department, will provide medication training to staff by a medical professional/pharmacist and will submit a copy of training certificates by POC due date 12/1/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/30/2023 12:49 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in no record of emergency drills conducts was available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2023
	Plan of Correction
1 2 3 4	Administrator will conduct an emergency drill with residents and staff, create a log, and submit a copy to the department by POC due date 12/7/23.

Type B

Section Cited

HSC

1569.695(d)

Other Provisions

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Emergency Disaster plan has not been updated to the most current or does not meet the most current version of Emergency Disaster plan version (12/21) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2023
	Plan of Correction
1 2 3 4	Administrator will create an emergency disaster plan that meets the criteria of LIC 610(12/21) and will submit a copy to the department by POC due date 12/7/23.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/30/2023 12:49 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: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(f)(1)

Other Provisions

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in facility does not have an evacuation chair by the stairwell which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2023
	Plan of Correction
1 2 3 4	Administrator will order and place evacuation chair at the end of the stairwell, will submit a picture and receipt to the department by POC due date 12/7/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

Page: 5 of 8

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
	VISIT DATE: 11/30/2023

NARRATIVE

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LPA reviewed medication for 3 clients, during medication review LPA observed an evening medication for resident #3 (R3) was finish and when asked if a refill was available staff explained the last pill was put on R3's ensure to be given to R3. During interviews a second staff confirm the medication is place in the R3's ensure. There is no physician's request to crush or hide medication in food or drinks.

Facility does not have an emergency evacuation chair. There is no record of last emergency drill, and the Emergency Disaster plan although it was last reviewed on 7/27/23 does not meet the criteria for the most current Emergency Disaster plan version (12/21).

LPA reviewed files for 3 residents and 5 staff. Administrator certificate was reviewed 6020655740 exp: 9/22/24.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Larry Ho and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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