197802496-9-22-2020-28-AS-MVAO-C56L83-20210722083116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197802496
Report Date: 09/17/2020
Date Signed: 09/22/2020 09:42:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/30/2019 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191230135403

FACILITY NAME:	MERIDIAN MANOR		FACILITY NUMBER:	197802496
ADMINISTRATOR:	NYCZAK, EWA		FACILITY TYPE:	740
ADDRESS:	1325 MERIDIAN AVENUE		TELEPHONE:	(323) 344-8700
CITY:	SOUTH PASADENA	STATE: CA	ZIP CODE:	91030
CAPACITY:	6	CENSUS: 6	DATE:	09/17/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Hanna Nowak-Brannon		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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9

Facility lacks sufficient staff to meet resident's needs
Facility does not allow residents' visitors
Facility does not allow resident's family choice of hospice agency
Facility does not feed residents a dinner time meal

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with the facility Assistant Administrator Hanna Nowak Brannon.
At today visit Resident's 1-4 were interviewed. Resident 5 did not respond to questioning and is non-verbal.
Assistant Administrator Hanna Nowak-Brannon was interviewed.
On initial visit 1/8/2020 the following occurred:
LPA toured the facility at 1:55PM which included 4 Resident Bedrooms and 2 Resident Bathrooms.
Kitchen was also toured. Sufficient and well balanced supply of food was observed. No safety concerns observed.
Administrator Ewa Nyczak was interviewed at 1:35 PM.
Caregiver's Hanna Nowak- Brannon and Emerlinda Esguerra were interviewed from 2:05 PM to 2:40 PM.
In regards to the allegation Facility lacks sufficient staff to meet resident's needs, based on interviews

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

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-20191230135403

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERIDIAN MANOR	FACILITY NUMBER: 197802496
	VISIT DATE: 09/17/2020

NARRATIVE

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conducted and information gathered there are 3 caregivers on the morning and afternoon shift.
Residents stated all their needs are met daily and there is sufficient staff. Staff interviewed stated the
numbers are sufficient to meet resident needs.
Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the finding is that this allegation is UNSUBSTANTIATED. In regards to the allegation Facility does not allow residents' visitors, based on interviews conducted and information gathered residents stated that they see visitors often and have seen visitors after 7.
They have never heard anyone say you can't have visitors
Staff interviewed stated that families will work 9 to 5 and often arrive after 8 and they have always been welcome.
Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the finding is that this allegation is UNSUBSTANTIATED. In regards to the allegation, Facility does not allow resident's family choice of hospice agency, based on interviews conducted and information gathered resident and staff both stated that family have their own choice of agency and there is no evidence to support that there is no choice allowed.
Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the finding is that this allegation is UNSUBSTANTIATED. In regards to the allegation Facility does not feed residents a dinner time meal , based on interviews conducted and information gathered residents stated they are fed 3 meals a day and snacks.
Lunch is the heavier meal and dinner lighter.
Residents interviewed stated meals are good and they are always served dinner.
Also stated that they can have food in between meals.
Staff stated there is always supper served and 3 meals.
LPA on initial visit 1/8/2020 toured the food supply and observed sufficient well balanced supply of food.
Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the finding is that this allegation is UNSUBSTANTIATED.

It should be noted that Resident 6 passed away on 12/27/2019.

Report e-mailed to facility for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

LIC9099 (FAS) - (06/04)

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