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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605216
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:06:52 PM

Document Has Been Signed on 09/21/2022 04:06 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:PASADENA MANSIONFACILITY NUMBER:
197605216
ADMINISTRATOR:EWA NYCZAKFACILITY TYPE:
740
ADDRESS:779 S. PASADENA AVENUETELEPHONE:
(626) 356-7575
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: 6CENSUS: 5DATE:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Ewa Nyczak - Administrator TIME COMPLETED:
04:25 PM
NARRATIVE
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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 Larry Ho caregiver and explained the reason for the visit. Ewa Nyczak administrator arrived 20 minutes later.

The facility is licensed to serve 3 ambulatory and 3 non-ambulatory residents age 60 and above. Non-ambulatory in ground bedrooms only. Facility is a two story residential home consists of (5) resident bedrooms, (1) staff bedroom, (2) resident bathrooms, (1) staff/guest bathroom, a living room, dining room/ office area, kitchen, laundry area, backyard/ garden that includes lattice with (table and chairs), detached garage for storage purposes. No large bodies of water were observed.

LPA Flores conducted a tour of the facility with Larry Ho Caregiver and observed the following:
Sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Sharps and cleaning supplies are kept in a cabinet next to refrigerator and was unlock at the time of the visit. Small refrigerator in kitchen had resident's medication and not kept under lock. Cleaning supplies were observed under sink in laundry area and accessible to residents. All resident bedrooms have sufficient lighting, furniture and bedding required. Smoke/Carbon Monoxide dectetors were tested and in working condition. Fire extinguisher was observed and last checked on March 2022. Resident bathrooms were observed to have grab bars, skid mats, and are in working condition. Water temperature was tested as follow: bathroom #1(B1) tested at 105.6 degrees F., and bathroom #2(B2) tested at 105.8 degrees F., which is within the required 105-120 degrees F. LPA Flores reviewed medication for 3 residents and files for 4 residents. Resident #1(R1) had PRN medication without a physician's order and medication out of original container. Resident #2 (R2) had PRN medication without a physician's order. Resident #3 (R3) had PRN medication without labels. R3 and Resident #4 (R4) do not have a yearly physician report on file and R4 status is non-ambulatory, R4's bedroom is located in the second floor. Staff files were reviewed and staff #2(S2) does not have a TB test on file. Administrator's certificate #6020655740 expiration date 9/23/24 was observed. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PASADENA MANSION
FACILITY NUMBER: 197605216
VISIT DATE: 09/21/2022
NARRATIVE
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Deficiencies have been noted on LIC 809D per Title 22 Regulations Division 6, Chapter 8.

Exit interview was conducted with Ewa Nyckzak administrator and a copy of this report, LIC 809D, technical advisories, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/21/2022 04:06 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/21/2022 at 03:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA MANSION
FACILITY NUMBER: 197605216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

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
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Based on observation, the licensee did not comply with the section cited above in cleaning,disinfecting supplies,and sharps were unlocked during the visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Administrator will ensure staff maintain all cleaning supplies and sharps lock at all times, will certify in LIC 9098 by 9/22/22.
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
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Based on observation, the licensee did not comply with the section cited above in medication cabinet, and resident's medication observed in refrigerator were not lock during the visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Administrator will ensure that medication is lock at all times, will certify and submit to the department by 9/22/22. Administrator is to submit picture of lock for refrigerator medication by 9/28/22.
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
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


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Page: 2 of 10
Document Has Been Signed on 09/21/2022 04:06 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/21/2022 at 03:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA MANSION
FACILITY NUMBER: 197605216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on file review, the licensee did not comply with the section cited above in S2 does not have a TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator will submit TB test clearance to the department by POC due date 9/28/22.

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
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 09/21/2022 04:06 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/21/2022 at 03:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA MANSION
FACILITY NUMBER: 197605216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during medication review, the licensee did not comply with the section cited above in 1 out of 3 residents, R1 medication was transfer from original bottle to another bottle which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator will provide training on medication proper storage section 87465 and submit agenda, and sign-in sheet by POC date 9/28/22.
Deficiency Dismissed
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and medication review, the licensee did not comply with the section cited above in R2 had PRN medication without prescription order, R3 did not have labels in PRN medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator will ensure all residents medication has the required labels and will submit pictures of the medication with labels to the department by POC due date 9/28/22.
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
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 09/21/2022 04:06 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/21/2022 at 03:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA MANSION
FACILITY NUMBER: 197605216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on file review, the licensee did not comply with the section cited above in R3 and R4 do not have a current annual physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator will obtain current physician's report and submit a copy to the department by POC 9/28/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


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Page: 5 of 10
Document Has Been Signed on 09/21/2022 04:06 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/21/2022 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA MANSION
FACILITY NUMBER: 197605216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(b)

87204 Limitations - Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nomabulatory shall not remain in rooms restricted to ambulatory residents.
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 R4 status is nonambulatory and resides in second floor which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Adminsitrator is to ensure R4 is place in a room per ambulatory status and will certify in LIC 9098 by POC due date 9/22/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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