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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605216
Report Date: 11/17/2025
Date Signed: 11/17/2025 04:04:23 PM

Document Has Been Signed on 11/17/2025 04:04 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: 3DATE:
11/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:09 PM
MET WITH:Ewa Nyczak, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA was greeted and was granted entry to the home by Luz Preza Mendoza, and the reason for the visit was explained. Ewa Nyczak, Administrator, arrived shortly after and continued to facilitate the visit.

The facility is licensed to serve (3) ambulatory and (3) non-ambulatory residents age 60 and over, non-ambulatory in ground bedrooms only. Hospice waiver approved for (2) residents. The facility is operating within the scope of its license. The two-story home is in a residential area of Pasadena, and it consists of the following:

First floor is made up of a receiving area, living room, dining room, kitchen, laundry room, (3) resident bedrooms, and (1.5) bathrooms. Second floor is made up of (3) resident bedrooms, (1) staff room, (2) full bathrooms, sunroom and attic. The facility also has a front and backyard with a patio area and detached garage.

The following was observed during today’s visit:

The facility is in good repair inside and out and walkways, passageways, ramps and exists are clear debris and obstructions. Furniture throughout the home is in good repair and there is enough seating for residents in care. Kitchen was observed clean. Appliances were also observed clean and operable. The facility has sufficient 2-day perishable and 7-day non-perishable supply of food. Sharps, cleaning supplies and other toxins are kept locked in a closet on the first floor of the home and inaccessible to residents. Resident bedrooms have the required lighting, furniture and bedding, and each room has sufficient closet space. Bathrooms were also inspected and have grab bars and non-slip mats in place. The water temperature was tested in the bathrooms and measures within the compliance range of 105 – 120 degrees F. ***Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/17/2025
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The facility has two fire extinguishers, one on each floor which were observed charged. Both fire extinguishers were last inspected on 10/22/25. Facility conducts safety drills quarterly. Last drill was conducted on 9/1/25. Exit doors are equipped with safety chimes which were tested and operating during today’s visit. LPA reviewed facility’s Emergency Disaster Plan and found it to be up to date. The facilily's Infection Control Plan was reviewed and also kept up to date. The home has a PPE station in the dining area which was observed stocked. Stairway evacuation chair was observed in good repair and readily available for use. The home is equipped with an electric chair lift which was also tested and observed operable during visit. Medication is kept centrally stored, locked and inaccessible to residents in care. The front and backyard are clean, and no pools or bodies of water were observed. The detached garage is kept locked. Shaded area for residents was observed and patio furniture is in good repair.

Due to time constraints, LPA Cota will return at a later time to complete annual inspection.

No deficiencies noted during today's visit. Exit interview was conducted with Ewa Nyczak, Administrator, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
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