197602744-8-17-2022-28-AS-DSIS-CWHKJ3-20231011075558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602744
Report Date: 08/17/2022
Date Signed: 08/17/2022 01:23:29 PM

Unsubstantiated

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
04/28/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210428080720

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: 89	DATE:	08/17/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Dana Denham; Health Services Director		TIME COMPLETED:	01:38 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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Licensing Program Analyst (LPA) David Sicairos conducted a subsequent unannounced complaint visit regarding the above stated allegation. LPA met with Dana Denham and explained the reason for the visit.

The investigation consisted of the following: during initial televisit conducted 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 today's visit, LPA interviewed Resident #2 - Resident #5 and Staff #1 - Staff #4. R1 was not interviewed as R1 passed away on 11/13/20.

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.

(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

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

LIC9099 (FAS) - (06/04)

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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
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: 08/17/2022

NARRATIVE

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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 white board located in the medication room to keep track and log any changes in resident conditions. Staff members interviewed indicated they do their best to keep residents from falling. Facility documented and reported R1's falls to Licensing. Facility also seeked 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.

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.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC9099 (FAS) - (06/04)

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