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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602744
Report Date: 10/10/2023
Date Signed: 10/10/2023 11:37:14 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
04/28/2021 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210428080720
FACILITY NAME:TERRACES AT PARK MARINO, THEFACILITY NUMBER:
197602744
ADMINISTRATOR:MARIA TERESITA QUIZONFACILITY TYPE:
740
ADDRESS:2587 E. WASHINGTON BLVD.TELEPHONE:
(626) 798-6753
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:112CENSUS: 91DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Quizon - AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Lack of care and supervision resulted in multiple falls and an injury.
INVESTIGATION FINDINGS:
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***** This report supersedes the original complaint investigation report dated 8/17/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.*****

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent unannounced complaint visit to supersede the report and deliver findings for the allegation listed above. LPA met with Maria Quizon, Administrator and explained the purpose of today's visit.

During the initial televisit conducted by LPA David SIcairos on 05/06/21, LPA interviewed Staff #1 and obtained copies from Resident #1 (R1) file such as Identification And Emergency Info Sheet, Physician's Report, Resident Assessment, Preplacement Appraisal, Incident Reports, and Death Report.

During the subsequent visit on 8/17/2022, LPA Sicairos interviewed Resident #2 - Resident #5 and Staff #1 - Staff #4. R1 was not interviewed as R1 passed away on 11/13/20.

During today’s visit, LPA Bennette Pena conducted a tour of the facility’s common areas and Memory Care Unit. LPA delivered the superseded report that contained additional information with no changes to the findings.*****CONTINUED ON LIC9099-C*****
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
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-20210428080720
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TERRACES AT PARK MARINO, THE
FACILITY NUMBER: 197602744
VISIT DATE: 10/10/2023
NARRATIVE
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***** This report supersedes the original complaint investigation report dated 8/17/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.*****

The investigation revealed the following: in regards to the allegation "lack of care and supervision resulted in multiple falls and an injury", it is alleged that R1 suffered multiple falls between June & July 2020 as a result of facility's lack of supervision and lack of communication amongst facility staff. R1 did not have a one-to-one caregiver while a resident of the facility. Interviews conducted with staff members denied the allegation. Staff members interviewed indicated that they will debrief each other during shift changes to make sure they are aware of what happened during the shift before theirs. Staff members indicated they utilize a communication binder and a whiteboard located in the medication room to keep track and log any changes in resident conditions. The communication binder contained community incident reports that were completed if there were incidents to be reported. Room checks were conducted every 2 hrs or as needed depending on the residents' needs. It was also indicated that the staff were aware of resident's falls and both the communication binder and whiteboard aided Caregivers in monitoring residents. LPA reviewed R1’s Resident Assessment Care Agreement (June 2020) showing personal Care Services and Care Plan under Memory Care (MC) unit. It indicated personal care for gait/balance and status checks due to having episodes and recent history of falls thus requiring safety status checks for fall prevention. Staff members interviewed indicated they do their best to keep residents from falling. Facility documented and reported R1's falls to Licensing. LPA reviewed the hospice records and community incident reports (Oct. 2020-Nov. 2020) regarding the resident’s falls which indicated that they were reported to Hospice, doctor, and Family member. Additionally, the reports indicated that there were no falls that led to injury that needed hospitalization and/or need to relinquish Hospice Services for Hospitalization. Facility also sought timely medical attention for R1 after her falls. Residents interviewed also denied the allegation. Residents interviewed indicated that they are happy with facility staff and the services they receive at the facility. LPA also reviewed the death report submitted to CCLD on 11/18/2020 indicating that a family member was notified on 11/13/20 at 3:45am of resident’s passing. During the tour of the Memory Care Unit, LPA observed (1) Med Tech and (2) Caregivers on duty. The staff to resident ratio at the MC Unit is to 5-7 Residents for all shifts; AM shift (6am-2pm), PM shift (2pm-10pm) and NOC shift (10pm-6am+1).

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.



Exit interview held, and a copy of this report was provided to Maria Quizon, Administrator.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
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