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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601976
Report Date: 02/17/2022
Date Signed: 02/03/2023 10:45:23 AM


Document Has Been Signed on 02/03/2023 10:45 AM - It Cannot Be Edited

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: 48DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director / Denise SuttonTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year Inspection. Upon arriving at the facility, LPA met with Executive Director / Denise Sutton who assisted with the visit. The facility is licensed to serve for a capacity of 60 residents (60 Non-Ambulatory, of which 5 may be bedridden) ages 60 and above. The facility has an approved Hospice Waiver (with total care) on file for nine (9) Residents. The facility does not have an approved Dementia Care plan as part of their operation and does not care for residents with dementia. During today's visit, LPA used the infection control domain.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Facility is located in a residential area. The building consists of a basement and 2 floors. The basement consists of a gym, laundry, offices, storage rooms, beauty shop, generator and is adjacent to the parking lot. The first floor consists of 25 resident rooms, kitchen, dining room, library, business office and storage rooms. The second floor consists of resident apartments, activity room, cafe and storage rooms.

The front grounds of the facility are well landscaped with a ramp that leads to the entrance. A shaded area with chairs is provided in the patio area facing Catalina Ave. The trash cans have covered lids. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises.
The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies and perishable food was stored in covered containers at the appropriate temperatures. No pesticides or poisons were stored in the food areas.

Due to time constraints, LPA had to terminate visit and will return on a later date to complete the Required - 1 Year inspection by touring random selection of resident rooms and reviewing medications/medication records.
No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to the Executive Director.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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