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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 06/17/2023
Date Signed: 06/17/2023 01:40:41 PM


Document Has Been Signed on 06/17/2023 01:40 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: 92DATE:
06/17/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Margaret Jay - Business Office ManagerTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced case management - annual continuation visit to conclude the following items on the care tool; Personnel Records, Resident Records, Residents with Special Health Needs. LPA met with Margaret Jay and explained the reason for the visit.

During this visit, LPA Flores reviewed 5 staff and 5 resident files. LPA interviewed 4 staff and 4 residents.
Resident #5(R5) was missing a TB test on physician's report and no other test results for a TB clearance were on file.

LPA reviewed training for staff, training for staff #3(S3) - #4(S4) did not cover the required postural support, restricted health conditions.

Administrator certificate was observed for Maria Quizon #6007396740 exp date: 9/28/23.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2023
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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Document Has Been Signed on 06/17/2023 01:40 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
GREATER LA AC/SC, 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: 06/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in staff #3-#4 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Administrator will provided additional topic to cover postural support, restricted health conditions and submit a copy to the department by POC due date 6/30/23.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in resident #5 does not have a TB clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Administrator will submit a copy of TB clearance for resident #5 to the department by POC due date 6/30/23.
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2023
LIC809 (FAS) - (06/04)
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