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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605216
Report Date: 09/28/2022
Date Signed: 09/28/2022 02:53:26 PM

Document Has Been Signed on 09/28/2022 02:53 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:
09/28/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Larry Ho - Caregiver TIME COMPLETED:
03:15 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced plan of correction(POC) visit to follow up on deficiencies given on 9/21/22. LPA Flores met with Larry Ho Caregiver an explained the reason for the visit.

On 9/21/22 LPA Flores conducted an annual inspection visit and cited the following deficiencies:

Type A Section 87309(a) Storage Space. LPA Flores observed cleaning, disinfecting supplies, and sharps were unlocked during the visit. On 9/28/22 LPA Flores observed all cleaning products have been removed and are under lock in garage. Deficiency cleared on 9/28/22.

Type Section 87465(h)(2) Incidental Medical and Dental Care Services. LPA Flores observed medication cabinet, and resident's medication observed in refrigerator were not lock. On 9/28/22 LPA Flores observed medication cabinet not locked, a medication box with lock was observed in the refrigerator. *Civil Penalties have been assets for Failure to Correct on LIC 421FC for a total of $600.*

Type A Section 87204(b) Limitations - Capacity and Ambulatory Status. LPA Flores observed resident #4 (R4) status is non-ambulatory and resides in second floor. On 9/28/22 LPA Flores observed R4 continues to reside in the second floor. *Civil Penalties have been assets for Failure to Correct on LIC 421FC for a total of $600.*

Exit interview was conducted with Larry Ho Caregiver and a copy of this report, LIC 421FC, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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