197802496-4-14-2022-28-AS-MGFS-CDGUT2-20220414155112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802496
Report Date: 04/14/2022
Date Signed: 04/14/2022 03:54:28 PM

Document Has Been Signed on 04/14/2022 03:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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:	04/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:02 PM
MET WITH:	Emerlinda Esguerra - Caregiver Ewa Nyczak - Administrator		TIME COMPLETED:	04:05 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(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, food and medication review. LPA Flores met with Emerlinda Esguerra caregiver and explained the reason for the visit. Administrator Ewa Nyczak arrived 40 minutes later. he facility is a single story home located in a residential neighborhood and has 4 resident bedrooms, 2 bathrooms, a living room, a dining room, a kitchen equipped with a laundry area, a sun room, a detached garage, a front and back yard. No bodies of water were observed. LPA Flores conducted a tour of the facility with Emerlinda Esguerra Caregiver and observed the following: Kitchen area - LPA observed sufficient non-perishable foods for 7 days, and not sufficient perishables for at least 2 days. Medications were observed in refrigerators door compartment. Sharps were observed locked in a drawer by the sink, cleaning supplies were observed under kitchen's sink and cabinet not lock at the time of the visit. Medication was observed in kitchen drawer and on top of counter next to the refrigerator not lock. Resident bedrooms have sufficient lighting, bedding, and furniture required. Bedroom #2(BR2) and #3(BR3) were observed to have dry water patches about 2 feet long per administrator from repaired water leaks and popcorn ceiling was observed to be peeling. Full bed rails were observed for resident #1(R1), #2(R2), and Resident #3(R3), half bed rails were observed for resident #4(R4). R2,R3,R4 do not have a physician order on file for bed rails. Bathroom #1(B1) and #2(B2) were observed with skid mats, and grab bars, water was tested in B1 at 101.4 degrees F., and B2 at 104.6 degrees F. Cleaning supplies were observed next to the toilet in B1 and under the sink in B2. Auditory devices were observed not working in main entrance door and exit door with access to the backyard which leads to the driveway and main entrance, and not activated at the exit door in the kitchen. Smoke detectors were tested and in working condition. Fire extinguisher was observed in the kitchen wall. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/14/2022

NARRATIVE

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LPA reviewed medication and files for R1,R2,R3,R4. R2 and R4 had prescribed medications which did not have labels on or were not stored in original container. R1 did not have a current physician report. LPA reviewed 3 staff files. Administrator certificate was observed for Ewa Nyczak #6020655740 expiration date 9/22/22.

Facility is screening visitors, staff, and residents but is not maintaining a visitors log. Staff were observed not wearing face coverings, N95 fit testing has not been done for staff, and signs have not been updated regarding visitation recommendations and hand washing guidelines.

Deficiencies were noted on LIC 809D and technical advisories were given under Title 22 Regulations.

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

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/14/2022 03:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERIDIAN MANOR	FACILITY NUMBER: 197802496
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

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 cleaning solutions were observed under kitchen sink, cabinet and under B2 sink unlock, and next to toilet in B1 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2022
	Plan of Correction
1 2 3 4	Administrator requested staff to remove cleaning solutions from each area and placed them under lock during this visit. Deficiency clear during visit.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 resident's medication was stored refrigerator's door compartment, drawer and on top of counter unlock which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2022
	Plan of Correction
1 2 3 4	Administrator requested staff to place medication in a container and place it in refrigerator in garage wich is not accessible to the residents and remove medication from drawer and on top of counter and placed them in medication cabinet under lock. Deficiency cleared during this visit.

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

Page: 3 of 13

Document Has Been Signed on 04/14/2022 03:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERIDIAN MANOR	FACILITY NUMBER: 197802496
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. 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 2 out of 4 residents, R2 and R4 prescribed medication did not have label which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2022
	Plan of Correction
1 2 3 4	Administrator will request medication or label from pharmacy to replace medication that does not have labels and submit a picture of the medication by 4/15/22.

Type A

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 3 out of 4 residents have bed rails and do not have physician's orders on file for R2,R3,R4 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2022
	Plan of Correction
1 2 3 4	Administrator will request physician's orders for R2,R3,R4 and submit a copy to the department by 4/15/22.

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

Page: 4 of 13

Document Has Been Signed on 04/14/2022 03:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERIDIAN MANOR	FACILITY NUMBER: 197802496
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(2)

Personal Accommodations and Services

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. 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 water patches from repaired leaks have popcorn ceiling peeling which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2022
	Plan of Correction
1 2 3 4	Administrator will have ceiling repair and submit pictures to the deparment by 4/28/22.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and documents review, the licensee did not comply with the section cited above in 1 out of 4 resident files reviewed, for R1 physician's report is not current which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/21/2022
	Plan of Correction
1 2 3 4	Administrator will obtain a current physician report for R1 and submit a copy to the department by 4/21/22.

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

Page: 5 of 13

Document Has Been Signed on 04/14/2022 03:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERIDIAN MANOR	FACILITY NUMBER: 197802496
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(j)

Care of Persons with Dementia

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. 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 3 out of 3 exits/entry to the facility auditory system is not in working condition for main entrance and exit door to the back yard or activated for exit door in the kitchen which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/21/2022
	Plan of Correction
1 2 3 4	Administrator will ensure auditory devices are in working condition at all times. Administrator replaced auditory devices in main entrance, activated auditory device in exit door in the kitchen, will replaced auditory device system in exit door to the backyard and submit a picture to the department by 4/21/22.

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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