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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 06/06/2024
Date Signed: 06/06/2024 02:35:15 PM


Document Has Been Signed on 06/06/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, 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: 94DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Maria Quizon - Administrator TIME COMPLETED:
02:47 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA Flores met with Maria Quizon 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, with multiple activity/common areas, a commercial kitchen, and a memory care unit. Facility currently has 11 residents under hospice.

LPA Flores conducted a tour of the facility with Maria Quizon and Maintenance Director and observed the following:
Facility is in good repair indoor and outdoor. All common areas are in good repair with sufficient seating area. Environmental cleaning was observed. There are different fireplaces in the common areas which are cover with a glass door. Kitchen area was observed clean. Sufficient food was observed for at least 2 days of perishables and 7 days of non- perishables. Special diets were listed. A total of 7 resident rooms were randomly observed and each room was observed in good repair with sufficient lighting, the required furniture, and bedding supplies. Oxygen tank without a stand was observed in room #118. Cleaning solution was observed in room #222 in the night stand, resident has a dementia diagnosis and should not store cleaning solutions. Bathrooms were observed in each room, each has the required grab bars, and skid floor in the showers, and are in good repair. Shower in room #312 was observed with mole in the shower floor. Water temperature was tested between 97.5 - 122.8 degrees F., which is not within the required 105-120 degrees F. Fire alarm sprinkle system and fire extinguisher were observed throughout the facility and last checked on 1/3/24. Carbon Monoxide/Smoke detectors were tested and are in working condition. LPA tested alert button in random rooms and staff responded within 2 minutes. Facility provided shaded seating areas outdoors.
Let us Know PUB 475, Local Ombudsman poster, and personal rights are posted by the mailboxes. Each stairwell has an evacuation chair on top of the stairwell. (CONTINUED ON LIC 809C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/06/2024
NARRATIVE
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The facility currently has residents in quarantine due to an infection outbreak. LPA and administrator observed a staff exit room #229 which is under quarantine, red zone sign at the door and PPE cart outside. Staff was observed exiting without PPE equipment, no hand hygiene procedures were observed being perform after exiting the room.
The facility has an egress system in place doors were tested and are in working condition.

LPA reviewed medication and files for 7 residents.

During this visit LPA completed the following domains of the CARE inspection tool:
Operational Requirements, Physical Plan/Environment Safety, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports.

LPA will return at a different time to finish the other domains.

Deficiencies were noted today per Title 22 Regulations.

Exit interview was conducted with Maria Quizon and a copy of this report, LIC 809D, and appeal rights provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/06/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87470(a)(1)(B)1
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (1) All staff and volunteers shall perform hand hygiene. (B) Hand hygiene shall be conducted as follows:  1. Immediately before and after resident care. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in staff exited room #229 in which resident is in quarantine and did not use hand sanitizer or proper measure to prevent infection spread which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator will schedule training for all staff regarding infection control procedures and procedure to provide care to any residents in quarantine by POC due date 6/7/24, will notify the department by 6/7/24, and will provide the training by 6/13/24.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 7 residents bathrooms were tested and water temperature tested as follow; room #118 at 122.8 degrees F., room #122 at 121.0 degrees F., room #308 tested at 97.5 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator will adjust water heater and will ensure that the water temperature is within the required 105-120 degrees F., at all times. Facility has a proposal for repairs to ensure the water temperature remains within 105-120 degrees F. will follow with the proposal and will maintain a log for the three rooms for the next 7 days and will submit a copy of the log by 6/13/24.
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: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 06/06/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/06/2024

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
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Based on observation, the licensee did not comply with the section cited above in 1 out of 7 rooms, cleaning solution was observed in room #222 were a resident with dementia resides which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator will ensure that cleaning solutions are not stored in the room, and will discuss with family regarding maintaining any hazardous materials in the room, will certify in writing to the department by POC due date 6/7/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 06/06/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(b)(2)
Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in staff was observed providing care to a resident with a contagious disease and staff was not wearing PPE supplies which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Administrator will schedule training for all staff regarding infection control procedures and procedure to provide care to any residents, wearing PPE while providing care for residents in quarantine by POC due date 6/7/24, will notify the department by 6/7/24, and will provide the training by 6/13/24.
Type B
Section Cited
CCR
87618(b)(3)(E)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in an oxygen tank was observed without a stand in room #118 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2024
Plan of Correction
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Administrator will contact hospice and request a stand for the oxygen tank or will ensure if it is not needed it is removed from the room by POC due date 6/13/24.
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: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
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