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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:19:48 PM


Document Has Been Signed on 06/15/2023 02:19 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:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Maria Quizon - AdministratorTIME COMPLETED:
02:35 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. 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. Facility currently has 5 residents under hospice.

LPA conducted a tour of the facility with Maria Quizon Administrator and observed the following:
Facility is in clean and good repair inside and outside. Facility's commercial was observed clean and keeps sufficient food for at least 2 days of perishables and 7 days of non-perishables. Common areas have sufficient sitting space for activities and fireplaces are covered. LPA observed 9 resident rooms; which had sufficient lighting, the required furniture, and bedding supplies. Water temperature was tested in each of the observed residents' room and tested between 104.3-114.6 which is within the required 105-120 degrees F. An evacuation chair was observed on top of each stairwell. LPA reviewed medication for 9 residents.

LPA reviewed LIC 610D last reviewed/updated on 11/10/20. Last fire drill was conducted on 5/25/23. LPA requested a copy of Liability Insurance.

No deficiencies were noted on LIC 809D per Title 22 Regulations a Technical Violation was noted.

Exit interview was conducted with Dana Denham Health Service Director and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
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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