197602744-11-9-2021-28-AS-MVAO-CCKUFE-20220316153236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602744
Report Date: 11/09/2021
Date Signed: 11/09/2021 02:47:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/02/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210802133554

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: 90	DATE:	11/09/2021
		UNANNOUNCED	TIME BEGAN:	11:51 AM
MET WITH:	Maria Quizon - Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not provide resident's medical records to resident's medical provider
Facility staff is not communicating with resident's medical provider

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Maria Quizon administrator and explained the reason of the visit.

The investigation consisted of the following: On 8/9/21 LPA Flores conducted interviewed with Administrator Maria Quizon. Reviewed files for staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5) and Resident #1(R1),#2(R2),#3(R3),#4(R4). LPA requested staff/resident roster, copies of personnel record, job description, and training, for S1,S2,S3,S4,S5, and copies of identification and emergency information, hospital's discharge, Medical Progress Notes, and physician's report for R1,R2,R3,R4 and interviewed S1. On 10/12/21 LPA Flores interviewed S2,S3,S4 over the phone. On 11/9/21 LPA Flores interviewed R1's responsible party, reviewed fax journal report for the period of 7/27/21 to 8/6/21, and reviewed staff file for staff #6, and #7. LPA Flores contacted Huntington Hospital Emergency Room, attempted to interview S6 and S8 and R2's responsible party and collected training logs. (CONTINUED LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

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-20210802133554

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERRACES AT PARK MARINO, THE	FACILITY NUMBER: 197602744
	VISIT DATE: 11/09/2021

NARRATIVE

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The investigation revealed the following: Regarding allegation: Facility staff did not provide resident's medical records to resident's medical provider. It is alleged hospital discovered that the medical records sent by the facility were the incorrect resident's medical records. Interview with administrator revealed that receptionist covering the front desk is responsible for providing paramedics an emergency packet with all the pertaining documents when a resident goes out to the hospital. On 7/31/21 R2 went out to the hospital at around 6:00pm and receptionist "new" to the position provided the documents for a different resident by mistake. Hospital contacted the facility at around 10:00pm during shift switch to notify facility of error and requested R2's emergency packet. Med Tech on duty during the night shift faxed the documents between 10:30pm to 11pm. Per administrator, staff noticed on 8/1/21 fax machine time was off by an hour and 20 minutes less. Interviews with 4 out 5 staff stated emergency packet is located in the front desk and if receptionist is not available Med Tech on duty is responsible for providing emergency packet to paramedics. Documents reviewed revealed receptionist hire date was 6/18/21 and has all pertaining training, receptionist was retrained on 10/12/21. Fax journal report date: 8/9/21 reveals facility faxed hospital's emergency room on 7/31/21 at 9:38pm. On 11/9/21 LPA Flores contacted emergency room at Huntington Hospital and verified faxed number on report. Facility has provided staff with training on 8/9/21 regarding Procedure and Documents to Paramedics and HIPPA laws.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Regarding allegation: Facility staff is not communicating with resident's medical provider. It is alleged hospital's staff tried several times to contact the facility but has only been able to speak with a medical tech. Per administrator, Hospital communicated with Med Tech who was the person in charge to provide any documentation on the night of the incident and faxed documents to the hospital.. Interviews with 5 out 5 staff working the weekend shift stated to not be aware of incident related to hospital attempting to contact the facility or facility providing wrong documents. LPA attempted to interview Med Tech on duty over the phone but was not able to as Med Tech in question no longer works at the facility as of 9/18/21. Interview with R1's responsible party revealed family was contacted between 8:00pm to 10:00pm, drove to hospital and notified hospital's staff not to be R2's responsible party after seeing R2. Documents reviewed revealed, fax journal report shows a confirmed fax to hospital's fax number at 9:38pm due to facility's fax been off by an hour and 20 minutes fax was most likely send between 10:30pm - 11:00pm. On 11/9/21 LPA Flores verified hospital's fax number with hospital's staff.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
Exit interview was conducted with Maria Quizon administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

LIC9099 (FAS) - (06/04)

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