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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802496
Report Date: 04/05/2024
Date Signed: 04/05/2024 12:54:45 PM


Document Has Been Signed on 04/05/2024 12:54 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
GREATER LA AC/SC, 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: 4DATE:
04/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:09 AM
MET WITH:Virginia Aguinaldo - CaregiverTIME COMPLETED:
01:11 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Virginia Aguinaldo and explained the reason for the visit.

The 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 covered front sitting area, and a back yard. Facility does not have large bodies of water.

LPA Flores toured the facility with Virginia Aguinaldo and observed the following:
Facility is in good repair indoor and outdoor. Living/dining/sun room have sufficient furniture that are in good repair. Kitchen was observed clean, sharps are locked in a drawer. Medication cups (prepared) were observed on top on counter top next to the refrigerator, hospice medication was observed in the freezer and a liquid medicine was observed in refrigerator door accessible to the residents and not properly stored. Sufficient food supplies were observed worth of at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies were observed in cabinet inaccessible. Each resident room (4) was observed with sufficient lighting, furniture, and bedding supplies. Resident #2(R2) is in hospice and has full bed rails in bed. Bathrooms (2) were observed clean, and in working condition, a bottle of cleaning solution was observed in bathroom #1(B1) accessible to the residents. Water temperature was tested in each bathroom and tested between 106.8- 107.1 degrees F., which is within the required 105-120 degrees F. Front and back yard are clean and have a shaded seating area.

LPA reviewed 4 residents medication and files. R2 does not have a bed rail request on file. Resident #3(R3) does not have a physician's report on file. Four residents are on hospice, facility has a hospice waiver for three only, facility is not operating within the license. LPA reviewed 5 staff files. Administrator certificate was observed for Ewa Nyczak #6020655746 exp: 9/22/24. Training was provided to staff.
(CONTINUED ON LIC 809C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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 04/05/2024 12:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: MERIDIAN MANOR
FACILITY NUMBER: 197802496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

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
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Based on observation, the licensee did not comply with the section cited above in cleaning solution was observed in B1 accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2024
Plan of Correction
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Administrator will submit in writing schedule for training to be provided to the staff by POC due date 4/8/24. Training will be provided on safety of storing cleaning supplies and other harmful items per section 87309 and will create a plan to ensure staff are following guidelines to maintain harmful items inaccessible to residents will submit a copy of training, log, duration, and plan to the deparment by 4/19/24.
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
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Based on observation, the licensee did not comply with the section cited above in resident's prepared medication was observed in kitchen's counter top, hospice medication was observed in freezer's door, and a liquid medication was observed in the refrigerator's door accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2024
Plan of Correction
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Administrator will certify in writing that medication will be stored properly, will schedule training for staff by pharmacist by POC due date 4/6/24. Administrator will provide training on medication storage per section 87465 and will provide copies of training description, log, duration of training, create a plan to ensure staff are following training guidelines, and will submit to the department by 4/19/24.
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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/05/2024 12:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: MERIDIAN MANOR
FACILITY NUMBER: 197802496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in facility is currently providing care to (4) residents in hospice and has a current hospice waiver for (3) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will submit either a hospice waiver increase or submit an exception hospice waiver letter request with required documents for (1) out of the (4) residents at the facility to the department by POC due date 4/19/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/05/2024 12:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: MERIDIAN MANOR
FACILITY NUMBER: 197802496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in PUB 475 was not observed posted at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will obtain a copy of PUB 475 and post it at the facility, will submit a picture of PUB 475 posted to the department by POC due date 4/17/24.

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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/05/2024 12:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: MERIDIAN MANOR
FACILITY NUMBER: 197802496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 residents, R3 does not have a physician's report on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will obtain a copy of physician's report for R3 and submitted to the department by POC due date 4/17/24.
Type B
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
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 4 residents, R2 has full bed rails and no physician's request was found on file or hospice file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Administrator will provide a copy of physician's order for full bed rails to the department by POC due date 4/17/24.
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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


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: MERIDIAN MANOR
FACILITY NUMBER: 197802496
VISIT DATE: 04/05/2024
NARRATIVE
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Infection Control plan, and Emergency Disaster plan (7/27/23) were reviewed. Let us Know PUB 475 poster was not observed posted at the facility.

Exit interview was conducted with Virginia Anguinaldo and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7