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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 09/01/2023
Date Signed: 09/01/2023 12:35:07 PM


Document Has Been Signed on 09/01/2023 12:35 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: 93DATE:
09/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Maria Quizon - Administrator TIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to follow up on incident report submitted to the department on 8/28/23. LPA met with Maria Quizon and explained the reason for the visit.

On 8/28/23 the department received an incident report which noted resident #1(R1) was not found during a morning check at 6:45am on 8/27/23. R1 was found at 8:00am in another residents room. Per administrator the procedure the staff should follow when a resident cannot be found in the facility is to contact family, search for the resident, and call the police to do a report if the resident is not found after checking all the rooms. Facility did not contact Local Police Department as resident was found at 8:00am.

Documents reviewed revealed R1 has dementia noted in physician's report dated: 5/18/22 and notes R1 cannot leave the the facility unassisted, manage own cash resources, and/or handle own medication. Per administrator R1 resides in the assisted living portion and not in the dementia unit. R1 gets checked in the morning before breakfast and before the end of the afternoon shift. LPA interviewed R1 and staff during this visit.

Per Title 22 Regulations facilities serving residents with dementia must follow dementia care regulations. Therefore, deficiencies are noted on LIC809D.

Exit interview was conducted with Maria Quizon 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: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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 09/01/2023 12:35 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: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2023
Section Cited
CCR
87468.2(a)(4)

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87468.2 ... Personal Rights of Residents...: (a)... facilities ... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered...

This requirement is not met as evidence by:
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Administrator will meet with family and determine whether they can meet the needs of R1 and will provide care for dementia care, provide training for staff on steps in case a dementia resident is missing, and submit the plan and training schedule by POC due date 9/2/23.
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Based on interviews and documents reviewed licensee did not ensure R1 whose physician report notes has dementia was provide dementia care at the facility which poses an immediate risk to the health, safety, or personal rights to the persons in care.
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Type B
09/15/2023
Section Cited
CCR87705(c)(5)

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87705 Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall...: (5) ... have an annual medical assessment ... and a reappraisal done at least annually,...

This requirement is not met as evidence by:
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Administrator will obtain a physician's report and conduct a reappraisal and submit a copy to the department by POC due date 9/15/23.
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Based on document review licensee failed to obtain an annual physician's report appraisal which poses a potential risk to the health, safety, or personal rights of the persons in care.
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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: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
LIC809 (FAS) - (06/04)
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