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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605216
Report Date: 02/08/2024
Date Signed: 02/08/2024 02:09:28 PM

Document Has Been Signed on 02/08/2024 02:09 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:PASADENA MANSIONFACILITY NUMBER:
197605216
ADMINISTRATOR:EWA NYCZAKFACILITY TYPE:
740
ADDRESS:779 S. PASADENA AVENUETELEPHONE:
(626) 356-7575
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: 6CENSUS: 3DATE:
02/08/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Larry Ho- Caregiver TIME COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conduted an unannounced plan of correction visit (POC) at the facility regarding deficiencies noted on 11/30/23 during an annual visit. LPA met with Larry Ho and explained the reason for the visit.

On 11/30/23 LPA Flores conducted an annual visit and noted the following deficiencies:

Type A - Section 87309(a): LPA observed bug killer spray and laundry detergent accessible to the residents. On 2/8/24 LPA observed cleaning supplies, chemicals, were under locked. Deficiency cleared as of 2/8/24.
Type A - Section 87309(b): LPA observed staff's medication was observed on top of kitchen's dining table, an apothecary accessible to the residents. On 2/8/24 LPA Flores observed medication locked on medication cabinet. Deficiency cleared as of 2/8/24.
Type B - HSC 1569.695(c): During the visit no record of emergency drills conducted was provided. On 12/7/23 Administrator provided emergency drill on December 6,2023. Deficiency cleared as of 12/7/23.
Type B - HSC 1569.695(d): Emergency Disaster plan has not been updated to the most current or does not meet the most current version of Emergency Disaster plan version (12/21). On 12/7/23 Administrator submitted a copy of Emergency Disaster plan. Deficiency cleared as of 12/7/23.
Type B - HSC 1569.695(f)(1): Facility does not have an evacuation chair by the stairwell. On 2/8/24 LPA Flores observed emergency evacuation chair on top of the stairs. Deficiency cleared as of 2/8/24.

Exit interview was conducted with Larry Ho and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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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