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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601976
Report Date: 01/17/2023
Date Signed: 01/17/2023 01:30:54 PM


Document Has Been Signed on 01/17/2023 01:30 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: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: 45DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Denise Sutton - Administrator TIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, food and medication review. LPA Flores met with Denise Sutton Administrator and explain the reason of the visit.

The facility is licensed to serve 60 non-ambulatory residents over the age of 60, of which 5 residents may be bedridden and has a hospice waiver for 9 residents. The facility is located in a residential area and consist of a multi level building with a dining room, library area, a commercial kitchen, courtyard, and patio.

LPA Flores conducted a tour of the facility with Denise Sutton administrator and observed the following:
Kitchen area is clean, refrigerator and pantry were observed with sufficient food for at least 2 days of perishables and 7 days of non- perishables. Resident's room #119,123,203,205,224,228,231,232 were observed each room is private with a private bathroom and has the required furniture, sufficient lighting, and are in good repair. Bathrooms have skid mats, grab bars, and are in good repair. Water temperature was tested in each bathroom observed and it tested between 116.7 and 121.4 degrees F., which is not within the required 105-120 degrees F. Library, activity area in second floor, staff lounges, laundry are were observed in good repair. Hallway to the left of the elevator in the 2nd floor around rooms #224 and #204 had a missing ceiling piece due to water damage which was observed in the ceiling above and in water makr was observed in the carpet. Per administrator water damage occurred after the rain. Facility has a contract dated 1/10/23 with roofing company for repairs to begin by 1/20/23. Signs are posted in the lobby and social distancing signs throughout the facility. Additional symptoms and precaution signs were not observed throughout. LPA review medication and files for 4 residents, and 4 staff files. Administrator certificate # 6009562740 expiration date 3/5/23 was observed and a copy of liability insurance was requested.
Deficiency has been noted on LIC 809D per Title 22 Regulations.
Exit interview was conducted with Denise Sutton Administrator 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: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
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 01/17/2023 01:30 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: DEL MAR PARK
FACILITY NUMBER: 198601976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in1 out of 8 resident rooms observed, room #123 water temperature tested at 121.4 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2023
Plan of Correction
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Administrator will ensure water temperature is maintain within the required 105-120 degrees F., at all times and submit a LIC 9098 by POC due date 1/18/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
LIC809 (FAS) - (06/04)
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