Pasadena Mansion

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual continuation visit today. LPA was greeted by Larry S. Ho, who granted entry to the home and facilitated the visit. Ewa Nyczak, Administrator was informed telephonically regarding today's visit the reason for the visit was explained. The initial annual visit was conducted on 11/17/2025. During today's visit, LPA reviewed (3) resident and (4) staff files and conducted medication review and documentation. Resident files contain current required documents. Staff files were also observed and contain criminal background documents, proof of education/training and Health/Tuberculosis screenings. Administrator's certificate is current and staff have First Aid/CPR training certification. Medication was observed locked and centrally stored. Medication was observed to be dispensed according to physician's orders, and medication administration is documented accordingly. No deficiencies noted during today's annual continuation visit.the state’s words, verbatim · CDSS document, Nov 20, 2025

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Nov 17, 2025

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Oct 21, 2024

Allegation investigated: 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.

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 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 providedthe state’s words, verbatim · CDSS document, Sep 24, 2024 · control 28-AS-20240105092231

Type of visit: POC

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.the state’s words, verbatim · CDSS document, Feb 8, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit regarding an incident reports that were not reported to the Community Care Licensing Department. LPA met with Ewa Nyczak (Administrator) and explained the reason for the visit. On 01/11/2024, during a complaint investigation (complaint control number: 28-AS-20240105092231) LPA Mora found out that the facility failed to report Resident 1 (R1) fall, hospitalization and death back in September 2023. During the visit, the Administrator could not remember the date of the fall and hospitalization. The death date is 09/18/2023. The deficiency cited is documented on the LIC809-D. Exit interview held and a copy of the report and appeal was provided.the state’s words, verbatim · CDSS document, Jan 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A)(D) · Plan of correction due date: Jan 11, 2024

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This regulation has not been met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The facility failed to report an incident reports regarding R1 fall, hospitalization and death to CCLD.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Administrator is to ensure that Title 22 Section 87211 regulations are met at all times. Administrator will submit incident reports and death report for Resident 1 (R1) fall, hospitalization and death to Community Care Licensing Division (CCLD) by 01/11/2024 5pm.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores 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. The facility is licensed to serve 3 ambulatory and 3 non-ambulatory residents age 60 and above. Non-ambulatory in ground bedrooms only. 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 in 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 pergola 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. Bug killing spray was observed next to sofa by the entrance to the living room. 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 apothecary cabinet was observed with residents medication to be dispensed accessible to the residents. Laundry area is clean, laundry detergent and bleach is accessible to the residents 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 between 107.7-109.5 degrees F. which is within the required 105-120 degrees F. Smoke/Carbon monoxide detectors were tested throughout the facility. Fire extinguishers were observed last checked on 3/13/21. Side yard is clean and has sitting area. No large bodies of water were observed. (CONTINUED ON LIC 809C) LPA reviewed medication for 3 clients, during medication review LPA observed an evening medication for resident #3 (R3) was finish and when asked if a refill was available staff explained the last pill was put on R3's ensure to be given to R3. During interviews a second staff confirm the medication is place in the R3's ensure. There is no physician's request to crush or hide medication in food or drinks. Facility does not have an emergency evacuation chair. There is no record of last emergency drill, and the Emergency Disaster plan although it was last reviewed on 7/27/23 does not meet the criteria for the most current Emergency Disaster plan version (12/21). LPA reviewed files for 3 residents and 5 staff. Administrator certificate was reviewed 6020655740 exp: 9/22/24. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Larry Ho and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 30, 2023

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.