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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601976
Report Date: 06/14/2021
Date Signed: 06/14/2021 02:59:35 PM

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:DEL MAR PARKFACILITY NUMBER:
198601976
ADMINISTRATOR:DENISE SUTTONFACILITY TYPE:
740
ADDRESS:990 EAST DEL MAR BOULEVARDTELEPHONE:
(626) 577-0215
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:60CENSUS: 44DATE:
06/14/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Denise Sutton - Administrator TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst(s) conducted a case management visit related to COVID recommendations during a complaint visit at the facility. LPA met with Denise Sutton - administrator and explained the reason of the visit.

During complaint visit LPA Flores arrived at the facility, staff #1(S1) open facility's entry door wearing face mask under her chin, introduced herself and waited for screening procedures. Staff did not screened LPA into the facility. As LPA waited by the door, LPA observed three staff in the dining room during lunch services gather in the back, two of the staff, staff #2(S2) and #3(S3) were wearing face masks under their chin. LPA spoke with administrator, administrator spoke to staff and reminded them of wearing face mask properly.

On 6/14/21, facility failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that facility staff #1,#2,#3, failed to wear face coverings while providing care and supervision to clients in care*, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Per California Code of Regulations, Title 22, Division 6 Chapter 8, deficiencies will be cited on attached LIC809D.

Exit interview was conducted with Denise Sutton administrator and a copy of this report, LIC 809D and appeal rights was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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: DEL MAR PARK
FACILITY NUMBER: 198601976
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2021
Section Cited

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87468.1 Personal Rights of Residents in all Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidence by:
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Based on observation facility did not ensure staff wear face mask properly. LPA observed S1 open facility's door wearing face mask under chin and did not screened LPA for COVID, and S2,S3 wearing face mask under chin around residents will poses an immediate Health, Safety, or Personal Righst risk to 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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2021
LIC809 (FAS) - (06/04)
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