<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 07/09/2024
Date Signed: 07/09/2024 02:44:44 PM


Document Has Been Signed on 07/09/2024 02:44 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: 96DATE:
07/09/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Maria Quizon - Administrator TIME COMPLETED:
02:50 PM
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
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction(POC) visit at the facility to follow up on deficiencies noted on 6/6/24 during an annual visit. LPA met with Maria Quizon and explained the reason for the visit.

On 6/6/24 LPA conducted an annual visit at the facility and noted the following deficiencies:
Type A - Section 87470(a)(1)(B)1 - Infection Control Requirements: On 6/6/24 LPA observed staff exited room #229 in which resident is in quarantine and did not use hand sanitizer or proper measure to prevent infection spread. On 7/9/24 LPA was provided copies of training provided to staff between June 8 - 12th on Hand washing for Safety and Infection. Deficiency cleared as of 7/9/24.

Type A - Section 87303(e)(2) - Maintenance and Operation: On 6/6/24 LPA tested water temperature which 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. On 7/9/24 LPA measured water temperature in room #122 at 107.5 degrees F., room #308 at 117.0 degrees F., room #118 at 107.7 degrees F. Deficiency cleared as of 7/9/24.

Type B - Section - 87470(b)(2) - Infection Control Requirements: On 6/6/24 LPA observed staff was providing care to a resident with a contagious disease and staff was not wearing PPE supplies. On 7/9/24 LPA obtained a copy of training provided between June 8 - 12th on Wearing PPE for Safety and Infection Control. Deficiency cleared as of 7/9/24.

Type B - Section - 87618(b)(3)(E) - Oxygen Administration - Gas and Liquid: On 6/24/24 LPA observed oxygen tank was without a stand in room #118. On 7/9/24 LPA observed the oxygen tank was removed. Deficiency cleared as of 7/9/24.

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: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1