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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601976
Report Date: 01/04/2024
Date Signed: 01/04/2024 01:47:21 PM


Document Has Been Signed on 01/04/2024 01:47 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: 54DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Denise Sutton - Administrator TIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Denise Sutton and explained the reason for 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 conducted a tour of the facility with Denise Sutton and observed the following:
Lobby, library, activity room, dining room, and other areas were observed furnished and in good repair. Fireplace in the library was observed covered. Chemical solutions and other harmful liquids were observed locked and inaccessible to residents. Resident's bedrooms (RB) were observed (7 rooms) randomly and each had sufficient lighting, the required furniture and bedding supplies. Each resident's has a personal bathroom which were observed in working condition. Water temperature was tested in each resident's bathroom and measured between 98.8 - 124.0 degrees F., which is not within the required 105-120 degrees F. In RB #222 water temperature tested at 124.0 degrees F., RB#233 tested at 123.4 degrees F., RB 231 tested at 98.8 degrees F., and RB#206 tested at 100.9 degrees F. Carbon Monoxide/Smoke detectors were tested in each room and are in working condition. Fire Extinguishers were observed throughout the building and were last checked on 4/25/23. No large bodies of water were observed. Facility has two courtyards, a smoking patio, and a smaller patio on the side of the building. The courtyard patios were observed with uneven cracks (3) on the ground of about 1.5 - 2ft in length. An emergency evacuation chair was observed on top of the front stairwell. The back stairwell did not have an emergency evacuation chair.
LPA reviewed files for 5 residents and 5 staff. Administrator certificate was observed for Denise Sutton #6009562740 exp. date: 3/5/25. LPA will return at a different time to finish the annual visit.
Deficiencies noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of 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: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 01/04/2024 01:47 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: 01/04/2024

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 in water temperature tested as follow in RB #222 water temperature tested at 124.0 degrees F., RB#233 tested at 123.4 degrees F., RB 231 tested at 98.8 degrees F., and RB#206 tested at 100.9 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Administrator will adjust water heater and certify in writing that will ensure water temperature is maintain within the required 105-120 degrees F., at all times and submit to the department by POC due date 1/5/24. Administrator will maintain a log of water temperature tested daily in each room at least twice a day and will submit log to the department by 1/11/24.
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: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 01/04/2024 01:47 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: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

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 in The courtyard patios were observed with three uneven cracks on the ground of about 1.5 - 2ft in length. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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Administrator will ensure the courtyard floor is repair and submit pictures of the repairs to the department by POC due date 1/18/24.
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: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5