197605216-5-5-2022-28-AS-SCOL-CFNT9D-20220623143145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605216
Report Date: 05/05/2022
Date Signed: 05/05/2022 04:49:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2022 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20220428142805

FACILITY NAME:	PASADENA MANSION		FACILITY NUMBER:	197605216
ADMINISTRATOR:	EWA NYCZAK		FACILITY TYPE:	740
ADDRESS:	779 S. PASADENA AVENUE		TELEPHONE:	(626) 356-7575
CITY:	PASADENA	STATE: CA	ZIP CODE:	91105
CAPACITY:	6	CENSUS: 4	DATE:	05/05/2022
		UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Administrator Ewa Nyczak		TIME COMPLETED:	04:58 PM

ALLEGATION(S):

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Staff kissed a resident.
Resident developed sepsis while in care.
Resident developed a UTI while in care.
Staff ignored resident.
Staff not serving nutritious meals to resident.
Staff not providing adequate supervision to resident's.
Resident is being confined to a reclining chair.
Facility did not issue a refund to resident's responsible party.
Resident's personal items are missing. 10) Staff administering medication to resident without approval

INVESTIGATION FINDINGS:

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LPA Alberto Lopez conducted an unannounced 10 Day Complaint Visit to this facility. LPA was greeted Staff Hanna Brannon and Administrator Ewa Nyczak arrived a short time later. LPA Lopez explained the purpose of today’s visit is to gather information regarding the above-mentioned allegations. LPA toured the home with caregiver and did not observed any health and safety issues at time of visit.
Investigation consisted of the following:

During visit, LPA's conducted interviews with Administrator. resident #1, Staff #1-#2, resident’s #2 conservator W1, and Representative from Norton Home Care Management W#2. Other residents #2-4 were not able to answer questions. Attempts to interview other resident’s responsible parties were unsuccessful.

(CONTINUE ON 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220428142805

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/05/2022

NARRATIVE

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Regarding Allegation:

Staff kissed a resident. Administrator and staff stated they do provide affection and a kiss on the head of forehead of the residents occasionally. W1 stated it was ok with W1 that staff do that for the resident and R1 stated she liked the affection that staff provides by hugging and kissing R1 on the forehead. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Regarding Allegation:

Resident developed sepsis while in care. Administrator denied that facility was responsible for sepsis or resident and review of documents did not reveal any information that facility was responsible. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Regarding Allegation:

Resident developed a UTI while in care: Investigation Revealed: Based on information gathered, observations of staff interactions with residents, and interviews conducted; LPA did not find evidence to support the allegations above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore, the allegation is UNSUBSTANTIATED

Regarding Allegation:

Staff ignored resident. Based on information gathered, observations of staff interactions with residents, and interviews conducted; LPA did not find evidence to support the allegations above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Regarding Allegation:

Staff not serving nutritious meals: Based on information gathered, observations of meals served, food supplies, staff interaction with the residents while assisting with meals, and interviews conducted; LPA did not find evidence to support the allegations above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

(CONTINUE ON 9099C)

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20220428142805

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/05/2022

NARRATIVE

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Regarding Allegation:

Resident being confined to recliner chair: Based on information gathered, observations of staff interactions with residents and taking them outside during visit, and interviews conducted; LPA did not find evidence to support the allegations above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Regarding Allegation:

Staff not providing adequate supervision to residents: Investigation Revealed: Based on information gathered, observations of staff interactions with residents, and interviews conducted; LPA did not find evidence to support the allegations above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Regarding Allegation:

Facility did not issue a refund to resident’s responsible party: Investigation Revealed: Based on information gathered, interviews conducted; LPA did not find evidence to support the allegations above. Administrator provided invoice and explained the charges and monies refunded to responsible party. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Regarding Allegation:

Resident’s personal items are missing: Investigation Revealed: Based on information gathered, and interviews conducted; and lack of inventory list when resident was brought to facility and left facility. LPA did not find evidence to support the allegations above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore, the allegation is UNSUBSTANTIATED

Regarding Allegation:

Staff administering medication to resident without approval. Investigation Revealed: Based on information gathered, and interviews conducted; LPA did not find evidence to support the allegation above.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur; therefore, the allegations are “Unsubstantiated”.

NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC9099 (FAS) - (06/04)

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