197802496-3-27-2025-28-AS-MGFS-DF6TTP-20250327150104

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802496
Report Date: 03/27/2025
Date Signed: 03/27/2025 03:01:33 PM

Document Has Been Signed on 03/27/2025 03:01 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/ DIRECTOR:	NYCZAK, EWA		FACILITY TYPE:	740
ADDRESS:	1325 MERIDIAN AVENUE		TELEPHONE:	(323) 344-8700
CITY:	SOUTH PASADENA	STATE: CA	ZIP CODE:	91030
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	03/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:44 AM
MET WITH:	Emerlinda Esguerra - Caregiver		TIME VISIT/ INSPECTION COMPLETED:	03:15 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 (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Emerlinda Esguerra Caregiver and explained the reason for the visit. The facility is licensed to serve (6) elderly clients ages 60 and above with a hospice waiver for (3) residents. 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, front sitting area, and a back yard. LPA reviewed the following CARE inspection tool domains during this visit: Infection Control: Infection control plan was reviewed which meets current regulations. Hand sanitizer and proper sanitation was observed during the visit. One staff does not have a TB test clearance on file. There is a responsible person and emergency training was provided to staff. Personal protective equipment was observed. Operational Requirements: Facility maintains a plan of operation. Facility has a current liability insurance. Facility is operating within the license. Physical Plant/Environmental Safety: LPA conducted a tour of the facility with Emerlinda Esguerra and observed the following: Facility was observed in good repair indoors and outdoors. Living room/dining room are clean, and providing sufficient sitting area, and lighting. Kitchen area is clean, sharps were observed locked in a drawer. Medications were observed in a drawer unlocked. Cleaning supplies were observed unlocked. Laundry area was observed in good repair. (CONTINUED ON LIC 809C)

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
	VISIT DATE: 03/27/2025

NARRATIVE

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Four (4) resident rooms were observed clean with sufficient lighting, furniture, and bedding supplies. Full bed rails were observed in bedroom #2. One (1) Bathroom was observed clean in working condition with grab bars and skid mats in the showers. Water temperature was tested at 105.8 degrees F., which is within the required 105-120 degrees F. Sun room was observed clean and furnished. Activities were observed in sun room. Front yard and back yard have a shaded seating area. Garage is used to stored additional food and cleaning supplies stored properly. There are no large bodies of water in the facility.
Carbon Monoxide/Smoke detectors were observed, tested, and in working condition. Fire extinguishers were observed and last checked on 1/15/21. Ramps, exit doors, and passageways are free of debris and obstructions.
Staffing: Administrator Ewa Knyczak arrived at the facility shortly after. Staff have current CPR/First Aid training on file. Night staff have been provided emergency training. Sufficient staff were observed.
Personnel Records/Staff Training: Administrator certificate was observed for Ewa Knyczak #7006214740 exp. date: 9/22/26. All staff records were available for review. LPA reviewed a total of 4 staff files which included medical assessment, TB clearance, background clearance, and training. One (1) staff was missing a health screening/TB clearance. Staff training files were not on file for the last 20 hours of yearly training.
Resident Rights/Information: Personal Rights, Let Us No poster (PUB 345), and Local Ombudsman posters were observed throughout the home.
Planned Activities: Activity materials were observed. One (1) resident was observed involved in activities during the visit. Outdoor area has a seating area to promote outdoor activities.
Food Service: Sufficient food supplies were observed of perishables for at least 2 days and non-perishables for at least 7 days. There are currently no residents on special diets. No pest was observed.
Incidental Medical and Dental: There is an area designated to centrally stored medication in a cabinet with a lock in the kitchen. LPA observed some medications in unlocked kitchen cabinets. Medications are label and in their original containers.
Resident Records/Incident Reports: Residents records were available for review. LPA reviewed a total of 5 resident files which contained medical assessment, TB clearance, admission agreement, an appraisal, a needs and care plan.
Disaster Preparedness: Emergency Disaster plan (LIC 610D 3/19) was last reviewed on 3/15/25. Last Emergency drill was conducted on 3/1/24 quarterly emergency drills have not been conducted since last.

(CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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
	VISIT DATE: 03/27/2025

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Residents with Special Health Needs: Postural support/bed rails were observed and physician's request were observed in residents files under hospice. There are no residents with restricted health conditions under care. Facility is following dementia regulations. Medical assessments for residents with dementia were observed within the last 12 months. Auditory devices were observed in each exit door. Facility currently has two resident on hospice and keeps hospice plan on file.

Deficiencies were noted per Title 22 Regulations and a technical violation was noted.

Exit interview was conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2025 03:01 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: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 medication bottles were observed in kitchen drawer, and cleaning supplies were observed in cabinet without locks, kitchen is accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2025
	Plan of Correction
1 2 3 4	Administrator will certify in writing that staff will ensure to maintain medications and cleaning supplies inaccessible to the residents at all times and submit a picture of the locks that will be install in the drawers by POC due date 3/28/25.

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.

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2025 03:01 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: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 4 staff did not have a health screening and TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	Administrator will obtain a health screening and TB test clearance for staff #3(S3) and submit a copy to the department by POC due date 4/3/25.

Section Cited

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Tony Vasallo	TELEPHONE: (818) 419-8131
Mary G Flores	TELEPHONE: (323) 981-3965
	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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