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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802496
Report Date: 04/22/2022
Date Signed: 04/22/2022 12:47:11 PM


Document Has Been Signed on 04/22/2022 12:47 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 MANORFACILITY NUMBER:
197802496
ADMINISTRATOR:NYCZAK, EWAFACILITY TYPE:
740
ADDRESS:1325 MERIDIAN AVENUETELEPHONE:
(323) 344-8700
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY:6CENSUS: 6DATE:
04/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Emerlinda Esguerra - CaregiverTIME COMPLETED:
01:00 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a plan of correction visit regarding deficiencies given on 4/14/22. LPA Flores met with and explain the reason for the visit.

On 4/14/22 LPA Flores conducted an annual visit the following deficiencies were given:
CCR 87465(h)(4) Incidental Medical and Dental Care Services - On 4/14/22 LPA observed 2 out of 4 residents, R2 and R4 with prescribed medication without labels or stored in the original container. On 4/22/22 LPA observed the following medications have labels for R2 and R4. Deficiencies cleared.
CCR 87608(a)(3) Postural Supports - On 4/14/22 LPA Flores observed residents #1(R1), #2(R2), and #(R3) have bed rails and do not have physician's orders on file. LPA Flores received bed rail order request for R1,R2, and R3 on 4/19/22 via fax. Deficiency cleared on 4/19/22.
CCR 87705(c)(5) Care of Persons with Dementia - LPA Flores observed R1 physician's report's is not current as required to have one per current year. LPA Flores received physician report on 4/21/22 which was faxed to the department. Deficiency cleared on 4/21/22.
CCR 87705(j) Care of Persons with Dementia - LPA Flores observed 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. LPA Flores observed all exit doors have an auditory device that chimes when open. Deficiency cleared on 4/22/22.

Exit interview was conducted with Emerlinda esguerra Caregiver and a copy of this report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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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