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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601976
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:18:04 PM

Document Has Been Signed on 12/10/2024 03:18 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/
DIRECTOR:		DENISE SUTTONFACILITY TYPE:
740
ADDRESS:990 EAST DEL MAR BOULEVARDTELEPHONE:
(626) 577-0215
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 124CENSUS: 58DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:39 AM
MET WITH:Dana Perez - Resident Service CoordinatorTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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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 Dana Perez and explained the reason for the visit.

The facility is licensed to serve 124 non-ambulatory residents over the age of 60, with 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, resident rooms, a medication room, two (2) courtyards, a patio, a smoking area in the first floor. The second floor has a seating area, a TV room, an activity area, several resident rooms. There are a total of three (3) stairwells. The baseman consist of staff offices, a therapy room, a laundry room, a beauty parlor, and staff break rooms. Each resident' room has a private bathroom.

LPA conducted a tour of the facility with Dana Perez and observed the following:
Facility is clean and in good repair indoor and outdoor. All common areas are in good repair and furnished. Required posters were observed in the hallway across the library. Commercial kitchen was observed clean, and stores sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. A list of special diets is kept in the kitchen. A total of (6) bedrooms were observed each have the required furniture, and bedding supplies, and sufficient lighting. Each resident's bathroom was observed in good repair, with skid strips, and grab bars. Shower's ceiling in room #106 was observed with a crack of about 4in. Water temperature was tested as follow; room #103, tested at 131.0 degrees F., #106 tested at 135.5 degrees F., #207 tested at 132.6 degrees F., #219 tested at 131.3 degrees F., and #226 tested at 135.1 degrees F., which is not within the required 105-120 degrees F. Half bed rails were observed in all (6) bedrooms. Oxygen signs were posted on room #123, oxygen was observed property stored. Courtyards/smoking areas are cleared, a patio with shaded seating area was observed. No large bodies of water were observed.
Fire sprinkler system and fire extinguishers were observed throughout the facility. Evacuation chairs were observed in each stairwell. Emergency food supplies and water were observed. Facility maintains a generator in the basement. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: DEL MAR PARK
FACILITY NUMBER: 198601976
VISIT DATE: 12/10/2024
NARRATIVE
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LPA reviewed medication and files for 5 residents. Resident #5 did not have a bed rail request on file. Five staff files and training were reviewed. Resident #2 and #4's physician's report note residents have dementia. Per file review residents are not wander risk or non-ambulatory.

A change of Administrator has taken place as of 11/4/24. Per current designee documents were mailed to the department. LPA requested that change of administrator documents are submitted to the department by 12/17/24.

Infection control plan and emergency disaster plan were reviewed. Last fire drill was conducted on 2/8/24.

Deficiencies were noted per Title 22 Regulations.

Exit interview was conducted an a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/10/2024 03:18 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/10/2024 at 02:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/10/2024

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 was tested between 131.0 - 135.5 degrees F., in resident's bathrooms which is not within 105-120 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Designee requested maintenance to adjust water temperature during this visit. Staff will keep a daily temperature water log for the next 7 days and will submit a copy to the department by 12/17/24.
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 Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/10/2024 03:18 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/10/2024 at 02:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in last fire drill was provided on 2/8/24 per records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Designee will submit a copy of fire drill conducted for each shift and will ensure they are conducted quarterly by POC due date 12/17/24.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in resident #5 did not have physician's bed rail request on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Resident Service Coordinator removed bed rails from resident #5's bed during the visit. Deficiency cleared as of 12/10/24.
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 Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/10/2024 03:18 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/10/2024 at 03:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in resident #2 and #4 have dementia and facility's exit door do not have an alert feature or auditory device to notify at exits which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Designee will either add auditory device/alert feature to exit doors, or provide wander guard feature to residents with dementia and provide pictures of either to the department by POC due date 12/17/24.
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 Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
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