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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:58:52 PM


Document Has Been Signed on 07/12/2022 03:58 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, 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: 89DATE:
07/12/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria Quizon - Administrator TIME COMPLETED:
01:00 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted a unannounced Plan of Correction visit (POC) at the facility to follow up on deficiencies given on 6/29/22. LPA Flores met with Maria Quizon Administrator and explained the reason for the visit.

On 6/29/22 LPA Flores conducted an annual visit and observed the following deficiencies:
877085(f)(2) Care of Persons with Dementia - LPA Flores observed dementia care kitchen's cabinet with cleaning supplies unlocked. On 7/12/22 LPA Flores observed dementia care unit kitchen's cabinet with cleaning supplies locked. Deficiency has been cleared during this visit.

Exit interview was conducted with Maria Quizon Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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