197602744-8-26-2024-28-AS-TVAO-D8MSRM-20240830140633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602744
Report Date: 08/26/2024
Date Signed: 08/26/2024 02:07:17 PM

Unsubstantiated

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
08/02/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240802160514

FACILITY NAME:	TERRACES AT PARK MARINO, THE		FACILITY NUMBER:	197602744
ADMINISTRATOR:	MARIA TERESITA QUIZON		FACILITY TYPE:	740
ADDRESS:	2587 E. WASHINGTON BLVD.		TELEPHONE:	(626) 798-6753
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	112	CENSUS: 92	DATE:	08/26/2024
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Leticia Martinez - Wellness Coordinator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Facility staff did not provide information on resident’s injury.
Staff are retaining residents that require a higher level of care.

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 Leticia Martinez and explained the reason for the visit.

The investigation consisted of the following: LPA requested a copy of staff/resident roster. LPA reviewed files for six (6) resident files and requested copies of physician’s report, admission agreement, appraisal needs and service plan, incident reports. On 8/9/24 Administrator provided copies of R1’s file to the department. On 8/26/24 LPA interviewed 5 residents and delivered findings regarding the above allegations.

The investigation revealed the following: Regarding allegation: Facility staff did not provide information on resident’s injury. It is alleged R1 sustained a fractured shoulder from a fall, but staff were unable to provide any details about the incident to the resident’s representative.
(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240802160514

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: 08/26/2024

NARRATIVE

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Interviews conducted with staff revealed that on 12/27/23 at around 11:00pm staff responded to R1’s pendant call. Once staff arrived at the room, they found R1 seating in the floor, with blood dripping from the head. R1 stated to have hit the head. Staff assisted and notified R1 that they will contact 911. R1 refused medical care. However, staff contacted 911 per protocol and send R1 out to be evaluated. Staff stated they contacted the family to notify of incident and no additional information was requested after the initial contact. Documents reviewed revealed incident report dated: 1/10/24 was submitted to the department to report the incident occurred on 12/27/23 regarding R1’s fall and assistance provided. Per incident report R1’s family member was notified of incident on the same day.

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.

Regarding allegation: Staff are retaining residents that require a higher level of care. It is alleged facility’s staff retained R1 and several residents with dementia in the assisted living. Interviews conducted with management team revealed that there are currently 3 residents from assisted living with a dementia diagnosis and waiting for an opening in their dementia unit. Per administrator the dementia unit is full and has a waiting list from which the residents from the assisted living have priority. The three residents have been diagnosed with dementia within the last 8 months, and are either under care with a private caregiver or are under hospice services. Management staff spoke with R1’s responsible party regarding change in condition and R1’s need of higher level of care. Documents reviewed revealed 3 out of 7 residents’ physician’s reports note residents have a dementia diagnosis which was updated within the last 8 months as the diagnosis was not noted on their previous physician’s report. One of these residents is on hospice care, another has a private care giver, and the last one has a location device in place. Facility has set up hourly safety checks for the residents, they provide a concierge at the lobby to observe who enters and exits the facility, and a sound device is located in their doors to alert staff that the residents have exit the rooms. Even though there are residents with dementia in the assisted living the facility is taking precautions and following regulations to provide care for these residents.

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 and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC9099 (FAS) - (06/04)

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