197602744-6-11-2021-28-AS-MGFS-C3VV9D-20210611161410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 06/11/2021
Date Signed: 06/11/2021 04:14:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	TERRACES AT PARK MARINO, THE		FACILITY NUMBER:	197602744
ADMINISTRATOR:	MARIA TERESITA QUIZON		FACILITY TYPE:	740
ADDRESS:	2587 E. WASHINGTON BLVD.		TELEPHONE:	(626) 798-6753
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	112	CENSUS: 82	DATE:	06/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:41 AM
MET WITH:	Maria Quizon - Administrator		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(s) Mary Flores and Luis Mora conducted an unannounced annual visit focusing on the infection control domain, food supplies, and medication. LPA(s) met with Maria Quizon administrator and explained the reason for the visit. Facility is licensed to served 32 ambulatory residents and 80 non-ambulatory, of which 5 may be bedridden. First floor is cleared for bedridden and there is fire clearance granted for egress exits and fire alarm. There are no large bodies of water in the property. Facility is a 3 story building. Emergency chair was observed in the 3rd floor stairway. Fire alarm system and fire extinguisher were observed throughout the facility. Facility tour was conducted with Maria Quizon the following was observed: Kitchen has sufficient food supplies of 2 days of perishables and 7 days of non-perishables. Refrigerator and freezer kept at the required temperature. Common areas were observed as follow; dinning room had a row of 3 square tables with 3 chairs each which does not follow the current 6 feet distancing recommendation, per administrator up to 3 residents have meals in each table. LPA(s) observed 11 randomly chosen rooms; #107,112,116,120,203,207,223,213,318,328, and . Smoke detectors were tested in the resident's rooms, resident's bathrooms had the proper grab bars, and skid mat, water temperature was tested between 112.1 - 115.3 degrees F, which is within the required range of 105 - 120 degrees F. LPA(s) observed 2 pairs of scissors, and cleaning solutions in resident's room #112. Dementia unit has own dinning/activity room, kitchenette with stove handles removed, LPA(s) observed cleaning products were locked under the sink, door with access to the garden had an auditory device that did not go off as the door was open, Room #120 within the dementia room had a French door accessible to the patio with auditory device that did not go off when door was open. LPA(s) reviewed medications for 8 residents, Resident #1(R1),#2(R2),#3(R3),#4(R4) #5(R5),#6(R6), #7(R7),#8(R8); medication was out of the original bubble pack container for the evening, bedtime, and next morning dose for R1,R2,R3,R4. there was not a 30 day supply of medication for R2, R4, R5, and there were PRN medications without a pharmacy label on the medication for R8 . (CONTINUED 809C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERRACES AT PARK MARINO, THE	FACILITY NUMBER: 197602744
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in cleaning solutions and scissors were observed by LPA(s) in room #112, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2021
	Plan of Correction
1 2 3 4	Administrator will ensure items that pose a danger to residents in room #112 will be removed, will certify by LIC 9098 and will submit to the department by 6/12/21.

Type A

Section Cited

CCR

87309(b)

Storage Space

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above in 2 out of 8 residents did not have a 30 day supply of medication. Medication for R2, R4 and R5 was listed in Medication sheet but the medication was not present, Med Tech and Wellness Director stated the medication will be deliver by 4pm, bubble packs showed medication was last given on 6/9/21 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2021
	Plan of Correction
1 2 3 4	Administrator will ensure all residents have at least 30 day supply of medication, will certify in LIC 9098 and submit to the department by 6/12/21.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

Page: 2 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERRACES AT PARK MARINO, THE	FACILITY NUMBER: 197602744
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above in 3 out of 8 resident's medication were not in the original container as staff were preparing medication for the next day which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2021
	Plan of Correction
1 2 3 4	Administrator will provide in service training to staff regarding medication by a pharmacist and will submit agenda and signing sheet to the department by 6/12/21.

Type A

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above in 1 out of 8 resident's PRN medication did not have a label on it for R8 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2021
	Plan of Correction
1 2 3 4	Administrator will provide in service training to staff regarding medication by a pharmacist and will submit agenda and signing sheet to the department by 6/12/21.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

Page: 3 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERRACES AT PARK MARINO, THE	FACILITY NUMBER: 197602744
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(j)

Care of Persons with Dementia

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in auditory devices were not functioning properly in doors within the dementia unit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2021
	Plan of Correction
1 2 3 4	Administrator will replace and ensure auditory devices are working properly throughout the facility, will certify by LIC9098 and submit to the department by 6/12/21.

Type A

Section Cited

CCR

87468.1(a)(2)

87468.1 Personal Rights of Residents in all Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accordd safe, healthful, and comfortable accomodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as S2 and vendor were not observe wearing face covering/mask under their chin around residents or staff which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2021
	Plan of Correction
1 2 3 4	Administrator will ensure that all staff are wearing face covering/mask according to CDC guidelines.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

Page: 4 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERRACES AT PARK MARINO, THE	FACILITY NUMBER: 197602744
	VISIT DATE: 06/11/2021

NARRATIVE

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Facility is following COVID 19 screening checks, surveillance testing recommendations, visitation recommendations, during the visit staff #2(S2), and hair stylist vendor were observed with their face covering under their chin which is not wear properly based on CDC recommendations. LPA(s) asked staff #3(S3), and staff #4(S4) regarding disinfecting procedures and requested to see disinfecting spray, S3 did not have disinfecting spray available, and S4 had windex, cleaning solution, S4 stated to clean high touch areas. S4 continued to look for disinfecting and found a bottle in housekeeping cart, there was no disinfecting supplies available in staff's break room.

Based on Title 22, Chapter 8 Division 6 deficiencies will be noted on 809D. Exit interview was conducted with Maria Quizon administrator and a copy of this report, LIC 809D, LIC 9102, and appeal rights was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

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