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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602744
Report Date: 03/09/2022
Date Signed: 03/09/2022 03:22:47 PM

Document Has Been Signed on 03/09/2022 03:22 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TERRACES AT PARK MARINO, THEFACILITY NUMBER:
197602744
ADMINISTRATOR:MARIA TERESITA QUIZONFACILITY TYPE:
740
ADDRESS:2587 E. WASHINGTON BLVD.TELEPHONE:
(626) 798-6753
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 112CENSUS: DATE:
03/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Maria Quizon - Administrator TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted a case management visit to give deficiencies related to a complaint investigation conducted on 11/09/21. LPA Flores met with Maria Quizon Administrator and explained the reason of the visit.

On 11/09/21 LPA Flores conducted a complaint investigation visit, during the investigation it was revealed facility did not ensure to safeguard confidentially within HIPPA law of resident #1's emergency packet documents during a transfer from facility to the hospital. Facility staff #1 provided paramedics emergency packet for resident #2 instead of resident #1. Hospital realized of the mistake upon contacting resident #2's responsible party. Responsible party arrived at the hospital and they were not able to identify resident #1 as a family member. Hospital contacted facility and requested the proper documents which were provided. This violates HIPPA law and confidentially requirements. In addition by providing the incorrect emergency packet documents facility did not ensure to safeguard the welfare of the resident.

Deficiencies are noted on LIC 809D per Title 22 Division 6 Chapter 8.

Exit interview was conducted with Maria Quizon administrator and a copy of this report, LIC 809D, and appeal rights were provided.


SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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 2
Document Has Been Signed on 03/09/2022 03:22 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/09/2022 at 02:21 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: TERRACES AT PARK MARINO, THE
FACILITY NUMBER: 197602744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2022
Section Cited
CCR
87506(c)(1)

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87506 Residents Records: (c) All information and records obtained from or regarding residents shall be confidential.
(1) The licensee shall be responsible for storing active...for safeguarding the confidentiality of their contents. ...

This requirement is not met as evidence by:
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Licensee will ensure that all staff is trained on 87506 and HIPPA law. Administrator will certify bysubmiting LIC 9098 by 3/10/22 and will ttrained staff and submit signing log and agenda to the department by 3/14/22.
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Based on interviews and document review licensee did not ensure staff were trained in safeguarding confidentially of resident #1 during a hospital transfer which poses a immediate health, safety, personal risk to persons in care.
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Type A
03/10/2022
Section Cited
CCR87464(f)(1)

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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).


This requirement is not met as evidence by:
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Licensee will provide all staff training on Care and Supervision, Health and Safety Code 1569.2. Administrator will certify by submitting LIC 9098 by LIC 9098 and will submit a copy of signing log, and agenda to the department by 3/14/22.
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Based on interivews and documents reviewed licensee did not ensure under care and supervision resident #1's welfare was not endangered when assisting transfer to the hospital which is an immediate health, safety, personal risk to the 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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022


LIC809 (FAS) - (06/04)
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