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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 07/22/2024
Date Signed: 07/22/2024 02:28:19 PM


Document Has Been Signed on 07/22/2024 02:28 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:
07/22/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Maria Quizon - AdministratorTIME COMPLETED:
02:45 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 deficiency noted on 7/9/24. LPA met with Maria Quizon and explained the reason for the visit.

On 7/9/24 LPA conducted a POC visit and on a case management visit noted the following deficiency:
87309 Storage Space: (a) On 6/6/24 LPA Flores conducted an annual visit and observed cleaning solution on resident's night stand in room #222 per physician's report resident has dementia. On 7/9/24 LPA conducted a POC visit and notices the cleaning solution on the same spot. Therefore, cited the deficiency during that visit. On 7/22/24 LPA toured room #222, cleaning solutions were removed, and obtained copies of resident's care plan regarding cleaning supplies and staff training.

Deficiency cleared during this visit.

Exit interview was conducted 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: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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