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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 07/09/2024
Date Signed: 07/09/2024 02:46:41 PM


Document Has Been Signed on 07/09/2024 02:46 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Maria Quizon - Administrator TIME COMPLETED:
03:00 PM
NARRATIVE
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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 deficiency:

Type A - Section 87309(a) - Storage Space: On 6/6/24 LPA observed cleaning solution in room #222 were a resident with dementia resides. On 7/9/24 LPA observed room #222 and cleaning solutions were observed in the residents' night stand.

Deficiency is being noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Maria Quizon and a copy of this report, LIC 809D, 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: 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)
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Document Has Been Signed on 07/09/2024 02:46 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: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2024
Section Cited
CCR
87309(a)

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87309 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:
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Administrator removed cleaning solutions during the visit, and will discuss and write a plan with family regarding maintaining any hazardous materials in the room and provide a copy, and provide training to staff regarding observing and reporting chemical in rooms of residents with dementia to the department by
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Based on observation, the licensee did not comply with the section cited above in LPA observed cleaning solution on 7/9/24 in room #222 were a resident with dementia resides which poses an immediate health, safety or personal rights risk to persons in care.
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 by POC due date 6/7/24.

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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: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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