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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802496
Report Date: 03/03/2026
Date Signed: 03/03/2026 01:58:31 PM

Document Has Been Signed on 03/03/2026 01:58 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:MERIDIAN MANORFACILITY NUMBER:
197802496
ADMINISTRATOR/
DIRECTOR:		NYCZAK, EWAFACILITY TYPE:
740
ADDRESS:1325 MERIDIAN AVENUETELEPHONE:
(323) 344-8700
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY: 6CENSUS: 5DATE:
03/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Staff#1 (S1) and
Ewa Nyczak, administrator 		TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Staff#1 upon arrival and Administrator Ewa Nyczak join shortly after. LPA explained the reason for the visit to Administrator. Facility annual fees are current.

The facility is licensed to serve six (6) elderly clients ages 60 and above with a hospice waiver for three (3) residents. Dementia waiver is in place. Today’s inspection consisted of applying CARE tool, conducting physical plant, reviewing staff/residents records, checking residents’ food supply/medication, and interviewing staff/residents.

Infection Control:

Facility maintains an infection control plan was on file. Staff were observed practicing safe hand washing. Hand sanitizing was observed throughout. Hygiene supply and sanitizing materials were observed.

(-continued on LIC 809C)

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2026
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: MERIDIAN MANOR
FACILITY NUMBER: 197802496
VISIT DATE: 03/03/2026
NARRATIVE
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Physical Plant & Environmental Safety:

The facility is a single story home located in a residential neighborhood and consists of four (4) resident bedrooms, two (2) bathrooms, a living room, a dining room, a kitchen, a laundry area, a sun room, a detached garage, front sitting area, and a back yard. Physical plant tour was conducted and observed the facility is in good repair in general. Facility is operating within capacity. Outdoor space is furnished, shaded, and accessible to residents. Passageways and exit areas were observed free of obstructions. Restrooms were observed clean. Water temperature was tested within 115 - 118.5 degrees F., which is within the required 105-120 degrees F per Title 22 requirement.

Staff/ Residents Records review:

Administrator certificate is current, and the expiration date is 9/22/26. Staff and residents’ records were available to review.

Food Service: The kitchen was clean. The required two (2) days of perishable and seven (7) days of nonperishable were observed and stored separately from toxic/cleaning supply.

Health-Related Services: Medications are centralized stored.

Disaster Preparedness: Emergency Disaster Plan LIC610E was observed and last reviewed on 2/07/25. A contingency plan was observed. Last emergency drill was conducted on 12/24/26.

(-continued on LIC 809C)

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
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: MERIDIAN MANOR
FACILITY NUMBER: 197802496
VISIT DATE: 03/03/2026
NARRATIVE
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Exit:

Deficiencies were noted during this visit and cited per California Code of Regulations, Title 22, Division 6. Exit interview was conducted with Staff#1 and LIC 809s and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/03/2026 01:58 PM - It Cannot Be Edited


Created By: Bonnie Tao On 03/03/2026 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERIDIAN MANOR
FACILITY NUMBER: 197802496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Disinfectants and cleaning solutions are stored in the unlocked bathroom cabinets, the unlocked storage room and the unlocked cabinet under the kitchen sink. Knives, scissors, sharp objects, and other similar items are stored in a unlocked kitchen drawer. Laundary detergine is left unattended outside the locked storage.
Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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Licensee agreed to lock disinfectants, cleaning solutions and sharp items. Provide in service training to ensure staff are following the regulation by POC due date.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Disinfectants and cleaning solutions are left unattended outside of the locked storage in the food supplies areas in the kitchen.
Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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Licensee agreed to lock disinfectants, cleaning solutions and stored separately from the food supplies. Provide in service training to ensure staff are following the regulation by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Bonnie Tao
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/03/2026 01:58 PM - It Cannot Be Edited


Created By: Bonnie Tao On 03/03/2026 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERIDIAN MANOR
FACILITY NUMBER: 197802496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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All residents' medication were centrally stored in the kitchen cabinet drawer UNLOCKED and accessible to residents.
Based on observation, the licensee did not comply with the section cited abovewhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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LIcensee agreed to lock the residents' medication cabinet and provide in-service training to ensure staff would keep the medication drawer locked by POC due date
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Alll residents' medication were transferred from the original bottles to medication boxes for 7 days. Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2026
Plan of Correction
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LIcensee agreed to stop transferring residents' medication to other medication boxes and provide in-service training to ensure staff are trained about handling medication by POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Bonnie Tao
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/03/2026 01:58 PM - It Cannot Be Edited


Created By: Bonnie Tao On 03/03/2026 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MERIDIAN MANOR
FACILITY NUMBER: 197802496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Kitchen ceiling has paint peeling at the area above the sink; Bathroom ceiling has paint peeling and mold at the shower areag; Stove burner (front, right burner) is not igniting, Audio device on the back exit door is not working,
Based on observation and testing, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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Licensee agreed to fix the issues and provided the proof of correction with pictures and labor invoices by POC due day.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Bonnie Tao
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2026


LIC809 (FAS) - (06/04)
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