197605216-9-24-2024-28-AS-RORN-D9WU4X-20241010151552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605216
Report Date: 09/24/2024
Date Signed: 09/24/2024 12:23:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/05/2024 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240105092231

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: 6	DATE:	09/24/2024
		UNANNOUNCED	TIME BEGAN:	08:14 AM
MET WITH:	Larry Ho - Caregiver		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility did not provide resident's records to authorized representative.
Facility did not provide authorized representative with an itemized list of charges.
Staff placed resident's mattress on the floor, resulting in resident sustaining bruises and abrasions.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Larry Ho (Caregiver) and explained the reason for the visit.

The investigation consisted of the following: On 01/11/2024, LPA obtained copies of staff & resident rosters and interviewed Administrator and Staff 1 (S1). LPA obtained copies of Resident 1 (R1) admission agreement, Identification and Emergency Information sheet, physician's report, resident appraisal, invoices for August 2023 - December 2023, certified mail receipts, medication list, home health notes, hospice notes and orders. Resident 1 (R1) was admitted to this facility on 08/02/2023 and resided here until 09/18/2023. Resident 1 (R1) passed away on 09/18/2023. During today's visit, LPA interviewed Resident 2 - Resident 7 (R2 - R7), reviewed all documents obtained on previous visit (01/11/2024) and delivered findings.

(Continue to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

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-20240105092231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PASADENA MANSION	FACILITY NUMBER: 197605216
	VISIT DATE: 09/24/2024

NARRATIVE

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Regarding the allegations "facility did not provide resident's records to authorized representative" and "facility did not provide authorized representative with an itemized list of charges" it is alleged that the administrator refused to provide R1's authorized representative with R1's records and a itemized list of the balance that R1's authorized representative owes to the facility. Administrator denied the allegations and stated they attempted four times to provide the records and the itemized list to R1's authorized representative. Administrator stated they mail it 4 times because it was allegedly not received. The Administrator showed LPA the envelope with the records and itemized list and USPS receipts. The Administrator used certified mail on 10/02/2023, 10/17/2023, 11/20/2023 and 12/11/2023. LPA confirmed that the facility was mailing it to the correct address. The 10/02/2023, 10/17/2023 and 12/11/2023 tracking number states it was delivered and the 11/20/2023 tracking number states that the item was refused by the addressee.

Regarding the allegation "staff placed resident's mattress on the floor, resulting in resident sustaining bruises and abrasions" it is alleged that R1's mattress was placed on the floor and resident sustained injuries over night while rolling on the floor. Administrator and staff denied the allegation and stated that R1 had a bed and was not sleeping on a mattress on the floor. Staff stated that for extra precaution a small mattress was placed near R1's bed just in case R1 rolled over and fell. Staff stated they would still check on all residents every two hours. Residents interviewed could not corroborate the allegation and stated they sleep on their beds and not on the floor.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview held and a copy of the report was provided

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC9099 (FAS) - (06/04)

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