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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605216
Report Date: 10/21/2024
Date Signed: 10/21/2024 05:03:50 PM

Document Has Been Signed on 10/21/2024 05:03 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PASADENA MANSIONFACILITY NUMBER:
197605216
ADMINISTRATOR/
DIRECTOR:		EWA NYCZAKFACILITY TYPE:
740
ADDRESS:779 S. PASADENA AVENUETELEPHONE:
(626) 356-7575
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: 6CENSUS: 5DATE:
10/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Ewa Nyczak- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) S Vaid conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Larry Ho and explained the reason for the visit. Administrator Ewa Nyczak arrived shortly after.

The facility is licensed to serve 3 ambulatory and 3 non-ambulatory residents aged 60 and above. Non-ambulatory in ground bedrooms only. Hospice waiver approved for two (2) residents. Facility is a two story residential home consists of (3) resident bedrooms, (1) staff/guest bathroom, 1 full bathroom, a living room, dining room, office area, kitchen, laundry area on the lower floor, (3) resident bedrooms, a sun room(storage), (1) resident bathroom, (1) staff bedroom and bathroom in the second floor. Backyard, a side garden that includes covered table and chairs, detached garage for storage purposes, and a front yard.

LPA toured the facility with Larry Ho and observed the following:
Facility is in good repair indoor and outdoor; passages are clear of obstructions. Living room, office, front entrance, and dining are clean with sufficient furniture and activities. Kitchen area is clean, pantry and refrigerator was observed with sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Staff medication container was observed in the kitchen's dining table, an cabinet was observed with residents medication to be dispensed inaccessible to the residents. Laundry area is clean, laundry detergent and bleach inaccessible to the residents placed in a cabinet next to the washer. Each residents room has sufficient lighting, furniture, and bedding supplies. There are 2 residents on hospice with full bed rails with request per hospice on file, and 1 resident on home health care with a half bed rail request on file per physician. Each bathroom is clean and in working condition with grab bars and skid mats, water temperature was tested in each bathroom and tested 106.4 and 109.4 in bathrooms and 108.0 degrees F for the kitchen, respectively for bathrooms and kitchen water taps, which is within the required 105-120 degrees F. Smoke/Carbon monoxide detectors were tested throughout the facility.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PASADENA MANSION
FACILITY NUMBER: 197605216
VISIT DATE: 10/21/2024
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 Fire extinguishers were observed last checked on 3/13/22. Side yard is clean and has sitting area. No large bodies of water were observed.

LPA reviewed medication for three (3) clients, during medication review LPA observed staff preparing afternoon medication in small cups to be administrated to the residents afternoon medication.

Facility does not have an emergency evacuation chair. The last emergency drill was held in Sept 2024, is preformed monthly, and the Emergency Disaster plan although it was last reviewed on 7/27/23.

LPA reviewed files for 5 residents and 3 staff. Administrator certificate was reviewed 6020655740 exp: 9/22/24. Renewal pending, renewal was sent in July 2024.

Exit interview was conducted with Ewa Nyczak and a copy of this report, was provided.

LPA experiencing printer difficulties, will email report to administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC809 (FAS) - (06/04)
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