197802496-3-9-2023-28-AS-MGFS-CPRUGU-20230309143455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802496
Report Date: 03/09/2023
Date Signed: 03/09/2023 02:35:23 PM

Document Has Been Signed on 03/09/2023 02:35 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 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: 5	DATE:	03/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ewa Nyczak - Administrator		TIME COMPLETED:	02:45 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 using the CARE tool at the facility. LPA met with Conrado Abaya - Caregiver and explain the reason for the visit. Administrator arrived 40 minutes later. 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 conducted a tour of the facility and observed the following: Facility is in clean and in good repair inside and out. Kitchen area was observed clean, sharps were located in a drawer to the left of the sink, cleaning supplies were stored under the kitchen sink, additional cleaning supplies were located in kitchen cabinet by doorway each area was unlocked during the visit. Medication was observed on the butter space of the refrigerator no lock was observed, and additional prescribed medication was observed to the left of refrigerator. Sufficient food was observed for residents for at least 2 days of perishables and 7 days of non-perishables. Dining room and living room were observed clean. Bedrooms #1-4 were observed and have sufficient lighting, furniture, and bedding supplies. Bathroom #1 and #2 were observed clean and in working condition with grab bars and skid mats. Water temperature was tested as follow: Water temperature tested at 110.3 degrees F. in bathroom #1 and 108.3 degrees F. in bathroom #2. Auditory devices were observed in main entrance and kitchen door and were off at the time of the visit. PUB 475 Complaint poster and Residents personal rights were not observed posted. LPA Flores reviewed (5) resident files and medication, resident #5(R5) is missing a physician report. LPA review (5) staff files and last training provided to staff was dated 7/18/21. Administrator certificate was review for Ewa Nyczak #6020655746 exp: 9/22/24. Liability Insurance was requested and it will be email to LPA by 3/10/23. Exit interview was conducted 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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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 03/09/2023 02:35 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: 03/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)(1)

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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 in kitchen cabinet were not locked during the visit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Licensee will certify via LIC 9098 and will schedule training for staff on regulation 87309 by 3/10/23 and submit training and sign in sheet by 3/17/23.

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 refrigerated medication was observed in the butter cupboard of refrigerator, prescribed medication was observed in counter between refrigerator and kitchen counter which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Licensee will ceritfy via LIC 9098 and will schedule training for staff on 87309 by 3/10/23 and submit trainig and sign in sheet by 3/17/23.

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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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
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: 03/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 drawer with knives and sharps located to the left of the kitchen sink was observed unlock which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Licensee will certify by LIC 9098 and will schedule training on 87705 for staff by 3/10/23. Administrator will submit training and sign in sheet by 3/17/23.

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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/09/2023 02:35 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: 03/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based record review, the licensee did not comply with the section cited above in 4 out of 5 staff files review did not have yearly training for 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/23/2023
	Plan of Correction
1 2 3 4	Licensee will provide proper training to staff and submit copies of a total of 20 hours in the required subjects for each staff to the department by POC due date 3/23/23.

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 5 resident files reviewed did not have a physician's report in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/23/2023
	Plan of Correction
1 2 3 4	Licensee will obtain physician's report for resident #5 and will submit a copy to the department by POC due date 3/23/23.

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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/09/2023 02:35 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: 03/09/2023

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 exit door/main entrance and kitchen exit door have an auditory device but it was not working at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/23/2023
	Plan of Correction
1 2 3 4	Administrator will ensure auditory devices are in working condition and staff maintain them on at all times in LIC 9098 by POC due date 3/23/23. Deficiency cleared during visit as of 3/23/23.

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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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