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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602744
Report Date: 03/14/2024
Date Signed: 03/15/2024 11:06:29 AM

Substantiated


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
11/07/2023 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231107162836
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:
03/14/2024
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Maria Quizon - AdministratorTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Resident developed a pressure injury due to staff neglect.
Facility staff did not seek timely medical attention for resident in care.
Staff did not notice a change in resident conditions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met Maria Quizon with and explained the reason for the visit.

The investigation consisted of the following: On 11/9/23 LPA Flores conducted a health and safety check, toured commercial kitchen, common areas, residents' rooms were not toured as facility has a COVID breakout. LPA requested the following documents for Resident #1 (R1); physician's report, admission agreement, identification and emergency information, medication sheet for November 2023, needs and service plan, facility's notes. Investigation Bureau Department (IB) investigator Peter Zertuche conducted interviews with 5 facility staff, wound care physician, and requested R1’s medical records. On 3/14/24 LPA Flores conducted interviews with 7 residents and 3 additional staff and delivered findings.

(CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
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 7
Control Number 28-AS-20231107162836
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: 03/14/2024
NARRATIVE
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The investigation revealed the following: Regarding allegations: Resident developed a pressure injury due to staff neglect, Facility staff did not seek timely medical attention to resident in care, and Staff did not notice a change in resident conditions. It is alleged R1 was diagnosed with unstageable wounds that developed at the facility for which R1 needed immediate hospitalization and facility staff did not notice the wound. On 10/31/23, R1 was visited at the facility by an occupational therapist. The occupational therapist had been providing services for movement and during the therapy noted the wound on the left heel. Occupational therapist informed facility staff and R1’s representative. R1’s representative contacted a wound specialist to evaluate R1. On 11/1/23, wound care doctor visited R1 at the facility and observed a 2cmx2.3cm sore on the left heel which was noted as “unstageable due to the presence of eschar covering the entire wound with no blood or drainage”. Wound care doctor recommended that R1 be taken to an “acute hospital for further evaluation”. R1 was taken to the hospital where the wound on the left heel was unstageable, measured at 3cmx3cm, and according to the physician the wound is at least Stage III, since it would take weeks to months for a wound to grow black eschar over the wound.

Interviews with staff revealed facility’s caregivers, med-tech, memory care director, and wellness director were aware of R1’s change in condition. Staff stated to have notified R1’s representative after they had noticed redness in the left heel. Although staff did not provide a clear date of when it was noted, staff stated the wound was observed for about 2 weeks. Staff also stated to not be trained to take care of wounds or prevention of wounds. Documents reviewed revealed, on 9/2/23, R1 complained of leg pain and contacted R1’s representative. A house doctor visited R1 and no signs of wound were noted during that visit. Based on the documents reviewed and interviews conducted, the facility staff were aware that R1 had developed the wound on the left heel while providing assistance with showers and assistance with activities of daily living. Staff noticed the wound, reported it to management, and R1’s representative. However, facility staff failed to obtain medical attention for R1 for at least 2 weeks, resulting in R1 obtaining an unstageable wound which measured 3cmx3cm.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
(CONTINUED ON LIC 9099C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20231107162836
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
87468.2(a)(8)
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Additional Personal Rights of Residents in Privately Operated Facilities: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement is not met as evidence by:
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Administrator will schedule training for staff on prevention, observation, and procedures upon observing wounds in residents by POC due date 3/15/24, and will submit a copy of log, training description and duration of training by 3/28/24.
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Based on interviews and documents reviewed licensee did not ensure measurements were taken to prevent R1 from developing an unstageable wound on the left heel which poses an immediate risk to the persons health, safety, or personal rights of the persons in care.
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***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining wound while in care. Refer to LIC 421IM***
Type A
03/15/2024
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions : (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
This requirement is not met as evidency by:
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Administrator will schedule training for staff on prevention, observation, and procedures upon observing wounds in residents by POC due date 3/15/24, and will submit a copy of log, training description and duration of training by 3/28/24.
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Based on interviews and documents reviewed licensee did not ensure R1 was provided medical care and not retained at the facility upon developing an unstageable wound on the left heel which poses an immediate risk to the persons health, safety, or personal rights of the persons in care.
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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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20231107162836
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidence by:
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Administrator will schedule training for staff on procedures, notifying responsible parties, and seeking medical care upon observing wounds in residents by POC due date 3/15/24, and will submit a copy of log, training description and duration of training by 3/28/24.
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Based on interviews and documents reviewed licensee did not ensure R1was provided medical care in a timely manner after developing a wound on the left heel which poses an immediate risk to the persons health, safety, or personal rights of the persons in care.
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***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining wound while in care. Refer to LIC 421IM***
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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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
11/07/2023 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231107162836

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:
03/14/2024
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Maria Quizon - Administrator TIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility staff do not provide resident basic laundry services.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Maria Quizon and explained the reason for the visit.

The investigation consisted of the following: On 11/9/23 LPA Flores conducted a health and safety check, toured commercial kitchen, common areas, residents' rooms were not toured as facility has a COVID breakout. LPA requested the following documents for Resident #1 (R1); physician's report, admission agreement, identification and emergency information, medication sheet for November 2023, needs and service plan, facility's notes. Investigation Bureau Department (IB) investigator Peter Zertuche conducted interviews with 5 facility staff, wound care physician, and requested R1’s medical records. On 3/14/24 LPA Flores conducted interviews with 7 residents and 3 staff and delivered findings.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20231107162836
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: 03/14/2024
NARRATIVE
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Regarding allegation: Facility staff do not provide resident basic laundry services. It is alleged R1's closet was seen with a basket full of dirty clothes and have not been washed. Interviews conducted revealed 6 out of 7 residents stated they do their own laundry and/or do not need assistance with laundry. 1 out of 7 residents stated that facility staff assist with laundry services once a week and does not have concerns. Interviews with staff revealed memory care staff provide laundry services for residents once a week and maintain a log of services. Documents reviewed revealed R1 received laundry services from 8/5/23 to 10/28/23 weekly by a caregiver.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Maria Quizon and a copy of this report was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20231107162836
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: 03/14/2024
NARRATIVE
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***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining wound while in care. Refer to LIC 421IM***

The issuance of an additional civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the serious bodily injury was due to neglect.

Exit interview was conducted with Maria Quizon and a copy of this report, LIC 9099D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7