197602744-5-12-2021-28-AS-MVAO-C42QXS-20210616123401

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602744
Report Date: 05/12/2021
Date Signed: 05/12/2021 05:00:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20200909161830

FACILITY NAME:	TERRACES AT PARK MARINO, THE		FACILITY NUMBER:	197602744
ADMINISTRATOR:	DION GALLARZA		FACILITY TYPE:	740
ADDRESS:	2587 E. WASHINGTON BLVD.		TELEPHONE:	(626) 798-6753
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	112	CENSUS: 91	DATE:	05/12/2021
		UNANNOUNCED	TIME BEGAN:	02:23 PM
MET WITH:	Maria Quizon - Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's items and money were stolen while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst(s) Mary Flores and Luis Mora conducted a complaint investigation for the above allegation.

The investigation consisted of the following: On 9/11/20 LPA Flores conducted telephone interviews with the director of health services, 1 resident, resident #1 (R1) , 4 staff (S1, S2, S3, S4), and a video call which consisted of interviewing R1, and an introduction to resident #2 (R2). The LPA also requested copies of resident and staff roster, face sheet, physician's report, admission's agreement, and any notes in resident's file for R1,R2,R3,R4,R5,R6,R7,R8 to be email. On 5/12/21 LPA Flores and Mora interviewed residents#1,#2,#3,#4 #5,#6,#7,#8 and reviewed residents files.

The investigation revealed the following: Regarding allegation: Resident's items and money were stolen while in care. It is alleged that someone has entered resident's apartment and is taking resident's stuff and resident stated that change has been missing as well. During interviews conducted with residents 7out of 9 residents interviewed stated that items or money have not gone missing from their rooms. (CONTINUED LIC 9099D)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20200909161830

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/12/2021

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
26
27
28
29
30
31
32

2 out of 9 residents stated to have small items missing but never reported to management or staff. Interviews with 6 out 6 staff revealed that residents have not reported to staff regarding any items missing from their rooms and staff do not handle any financial needs of the residents. Documents reviewed revealed there are no incident reports or police reports related to missing items between August 2020 to May 2020 for residents. On September 2020 facility assisted R1 with obtaining power of attorney and re-assessed resident for change in condition as R1 was having difficulties keeping track of finances. On 9/10/20 LPA attempted to obtained further information regarding allegation with reporting party, however was unable to contact reporting party.

Based on LPA's interviews, and file review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED.

Exit interview was conducted with Maria Quizon, and a copy of the report 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: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2