197602744-6-29-2022-28-AS-MGFS-CFUU5E-20220629151637

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 06/29/2022
Date Signed: 06/29/2022 03:16:54 PM

Document Has Been Signed on 06/29/2022 03:16 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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:	06/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:09 AM
MET WITH:	Maria Quizon - Administrator		TIME COMPLETED:	03:30 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(s) Mary Flores conducted an unannounced annual visit with focus on the infection control domain, food supplies, and medication. LPA Flores met with Maria Quizon administrator and explained the reason for the visit. Facility is licensed to served 32 ambulatory residents and 80 non-ambulatory, of which 5 may be bedridden. First floor is cleared for bedridden and there is fire clearance granted for egress exits and fire alarm. There are no large bodies of water in the property. Facility is a 3 story building, with multiple activity/common areas, a commercial kitchen, and a memory care unit. Fire alarm sprinkle system and fire extinguisher were observed throughout the facility. LPA conducted the tour with Raul Sandoval Maintenance Director and observed the following: Commercial Kitchen was observed to have sufficient food for at least 2 days worth of perishables and 7 days of non-perishables. Sharps and cleaning supplies are not accessible to residents. All common areas have signs posted for social distancing, cough/sneeze etiquette. Memory care unit was observed and the cabinet under kitchen's sink with cleaning supplies was unlocked, cleaning supplies accessible to memory care residents. The following rooms were randomly chosen and observed #103,118,121,207,223,232,308,317,324. Each room has all required furniture, sufficient lighting, and in good condition. A water patch was observed in room #324 LPA was provided a copy of roof work order dated 1/28/22. Resident's bathrooms corresponding to the observed rooms were observed to have skid floors and grab bars, water temperature was tested in each bathroom, water tested between 106.5 - 110.4 degrees F., which is within the required 105-120 degrees F. LPA observed outside room #214 which is currently under quarantine and facility is following infection prevention guidelines. Infection control hand washing signs were not observed in kitchen hand washing station, memory care kitchen sink area, and third floor staff break room. LPA Flores reviewed medication and files for resident #1,#2,#3,#4, #5,#6,#7,#8,#9, residents #3, #8, and #9 were missing medication prescribed by the physician. (CONTINUED LIC 809C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/29/2022

NARRATIVE

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Facility does not handle communication with physician or pharmacist as the family or representative requested to handle all communication, facility has noted on medication sheet that the medication is not available. Files for staff #1,#2,#3,#4,#5,#6 were reviewed. Administrator's certificate was observed # 6007396740 with expiration date: 9/28/21, administrator has copies of documents submitted to the department for renewal.

Deficiencies have been noted on LIC 809D per Title 22 Regulations and technical advisory notes were provided during this visit.

Exit interview was conducted with Margaret Jay Business Office Manager and a copy of this report, LIC 809D, technical advisories, and appeal rights were provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 06/29/2022 03:16 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
CCLD Regional Office, 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: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in memory care unit kitchen's sink was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2022
	Plan of Correction
1 2 3 4	Licensee will ensure to schedule in-service training regarding 87705 to staff by 6/30/22 and will submit a copy of in-service sign-in log to the department by 7/5/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC809 (FAS) - (06/04)

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