The Terraces at Park Marino

Type of visit: Required - 1 Year

The narrative section of the state’s online copy of this report is blank.

Type of visit: Office

Licensing Program Analyst (LPA) Mary Flores, Regional Manager (RM) Tony Vasallo, Executive Director Adam Khalifa, and Administrator Maria Quizon met via Teams Meeting to discuss the status of the facility. The following was discussed during today's meeting: Rebuild of the facility: On 12/15/25 plans were submitted to the city for approval to begin re-building. The facility will maintain most of their original plans with updates to meet current Building, Fire, and Safety codes. Once the construction is completed and a fire clearance is obtain, the licensee will notify the department and a visit will be conducted prior reopening the facility. RM Vasallo and Executive Director discussed the appeal response received and the process of second level appeal. Exit interview was conducted with Maria Quizon and a copy of this report was email.the state’s words, verbatim · CDSS document, Jan 7, 2026

Allegation investigated: Resident received unexplained injury due to neglect

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint visit regarding the above allegation. Due to the Eaton fire, facility was destroyed and therefore this visit is being completed via telephone. LPA contacted administrator, Maria Quizon over the phone and explained the reason for the investigation. The investigation consisted of the following: On 8/6/25 LPA Flores conducted an initial investigation via telephone, interviewed administrator, and requested a resident/staff roster. On 8/20/25 LPA Flores attempted to contact administrator for skill nursing facility adjacent to facility. On 8/27/25 LPA Flores attempted to request a copy of Los Angeles Sheriff’s department (LASD) report. On 10/22/25 Investigator Bureau Amina Luckett from the Investigation Department Bureau provided LPA Flores a copy of LASD report requested. On 10/23/25 LPA Flores contacted administrator and delivered findings. (CONTINUED ON LIC 9099C) Unfounded During the course of this investigation, it was found that the alleged victim did not reside or was a potential resident at the facility based on interview conducted with administrator and document review revealed resident roster received on 1/9/25 and on 8/7/25 does not list alleged victim as a resident. There are no records that indicate alleged victim resided at the facility prior to 1/8/25. This agency has investigated the complaint alleging Resident received unexplained injury due to neglect. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview was conducted with Maria Quizon via telephone a copy of this report was email to administrator for signature.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 28-AS-20250729094110

Allegation investigated: Staff did not evacuate resident during mandatory evacuation.

*This supersedes report created on 5/19/25 as findings changed from unsubstantiated to substantiated.* Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation regarding the above allegation. Due to the Eaton fire, facility was destroyed and therefore this visit is being completed via telephone. LPA contacted administrator, Maria Quizon over the phone and explained the reason for the subsequent investigation. The investigation consisted of the following: On 2/19/25, LPA Flores conducted a complaint investigation over the phone and interviewed 4 staff. On 2/26/25, LPA contacted Pasadena Fire Department (PFD) to request service logs. On 3/10/25, LPA interviewed 2 additional staff over the phone and attempted to contact PFD Fire Captain. On 3/12/25, LPA submitted a service request to Pasadena Police Department (PPD) and Los Angeles Sheriff Department (LASD). On 3/13/25, LPA conducted a collateral visit and interviewed 7 residents (R1-R7). On 4/7/25, 4/14/25, and 4/23/25 LPA contacted PFD Fire Captain. (CONTINUED ON LIC 9099C) Substantiated On 4/25/25, LPA conducted interview with one responsible party over the phone. On 6/4/25, LPA conducted a collateral visit and interviewed an additional resident. On this same day, LPA interviewed Resident #8 (R8)’s responsible party over the phone. On 6/6/25 and 7/3/25, LPA contacted PFD Fire Captain to ask additional questions. On 6/20/25, LPA interviewed R1’s responsible party for additional information. On 7/8/25, LPA interviewed 3 staff for additional information. 7/15/25, LPA reviewed Eaton fire status reports on the California Fire website. The investigation revealed the following: Regarding allegation: Staff did not evacuate resident during mandatory evacuation. It is alleged that a resident was not evacuated by staff during a fire evacuation. A timeline of the events was established from interviews conducted with facility staff, residents, responsible parties, and fire personnel. On 1/7/25 at approximately 6:30pm, staff observed the fire at the mountain range near the facility. Business Coordinator met with staff to discuss and coordinate evacuation per their emergency disaster plan. Between 7:00pm – 7:30pm, staff began the evacuation process by transferring residents from each floor into the lobby of the building. Staff then awaited instructions from the fire department to evacuate the building. At approximately 8:30pm, staff was instructed by the fire department to evacuate the building. Per review of Fire Department Status Reports the area or zone where the facility was located received evacuation orders on 1/7/25 at 7:27pm. Interviews with staff revealed that upon observation of the fire, staff began calling family members to notify them of the situation and indicated they could pick up their loved one if possible. Staff observed the ambers closer to the facility between 7:00pm – 7:30pm and began knocking on residents’ doors. Staff began assisting residents down the stairs and additional staff not on duty at the time arrived to assist. At approximately 8:30pm, fire department arrived, and staff began to assist residents out of the building. Four of the staff interviewed indicated that between 8:45pm and 9:15pm they attempted to enter the facility again to continue to evacuate residents. However, staff was instructed by the fire department to not enter the facility. Interviews conducted with residents revealed some had been assisted by a staff member to evacuate the building. Some residents also reported that a family member picked them up before the evacuation took place. R1 stated that at approximately 6:00pm a caregiver asked R1 to wait in the room. Per R1, no one returned and was evacuated out of the building by a family member. Another resident, R8 stated to have been evacuated by 2 gentlemen, who R8 was unable to identify as they didn’t appear to be staff members. Interviews conducted with residents’ responsible parties revealed a family member stated to have entered the facility to assist R1 out of the building. R8’s responsible parties were aware of the fire but stated that they were not searching for R8 during the fire. (CONTINUED ON LIC 9099C) Interview conducted with PFD Fire Captain revealed facility staff, Pasadena Police Department, and fire department had collaborated to evacuate the residents on 1/7/25. Per Fire Captain, their department received a request from R8’s responsible party through Pasadena’s Police Department to search for R8 in room #326. The fire department evacuated R8 from room #326 and was the last resident to be evacuated from the building. Based on interviews conducted and records reviewed, it was confirmed that at least one resident was left in their room and had to be evacuated by the fire department. Therefore, the preponderance of evidence standard has been met and the allegation is found to be substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 28-AS-20250214161239

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 8, 2025

87468.2 Additional Personal Rights of Residents...: (a)...residents in... residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision,... are delivered by staff that are ... competency to meet their needs. This requirement is not met as evidence by: Based on interviews conducted on 1/7/25 R8 was not evacuated by facility's staff and was evacuated by PFD which poses an immediate risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Administrator/Licensee will submit a plan to updated Emergency Disaster procedures by POC due date 8/8/25 and will submit a copy of updated Emergency Disaster Plan/procedures by 8/21/25.

Type of visit: Required - 1 Year

The narrative section of the state’s online copy of this report is blank.

Allegation investigated: Staff did not evacuate resident during mandatory evacuation.

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. Due to the Eaton fire facility was destroyed and therefore this visit is being done via telephone. LPA contacted administrator Maria Quizon over the phone and explained the reason for the visit. The investigation consisted of the following: On 2/19/25 LPA Flores conducted a complaint investigation visit over the phone and interviewed 4 staff. On 2/26/25 LPA contacted Pasadena Fire Department (PFD) to request service logs. On 3/10/25 LPA interviewed 2 additional staff over the phone and attempted to contact PFD fire captain. On 3/12/25 LPA submitted a service request to Pasadena Police department (PPD) and Los Angeles Sheriff Department (LASD). On 3/13/25 LPA conducted a collateral visit and interviewed 7 residents. On 4/7/25, 4/14/25, 4/23/25 LPA contacted PFD fire captain. On 4/25/25 LPA conducted interview with one responsible party over the phone. (CONTINUED ON LIC 9099C) Unsubstantiated On 5/6/25 LPA Flores interviewed 1 additional responsible party and attempted to interview 2 additional responsible parties. On 5/19/25 Fire Captain provided a response to the interview questions. On 5/19/25 LPA delivered findings for the above allegation via telephone. The investigation revealed the following: Regarding allegation: Staff did not evacuate resident during mandatory evacuation. It is alleged a resident was not removed from the facility on 1/7/25. The following timeline of the events was provided by the staff. On 1/7/25, at around 6:30pm staff observed the fire at the mountain. Business Coordinator met with staff on duty and discuss assigned tasks to coordinate the evacuation. Staff notified residents and responsible parties of residents in placement of the situation. Between 7:00pm – 7:30pm staff began the evacuation process and gather residents in the lobby of the building. At around 8:15pm staff and residents were waiting for fire department instructions to evacuate the building. At around 8:30pm staff were instructed by fire department firefighters to evacuate the building. Between 8:45 pm – 9:15pm staff attempt to gain access to the facility to conduct another check of residents in the floors but were instructed by fire department not to enter the facility. Interviews conducted with 7 residents revealed, 6 out of 7 residents stated they observed the evacuation process, staff knock at residents’ doors, residents were directed to exit the rooms, residents were assisted down the stairs, residents were directed to the lobby for evacuation. Some residents observed other residents being carried down the stairs by staff. One of the six residents stated staff knock at their door and asked them to exit quickly. Two of the six residents confirmed that the facility had conducted evacuation drills in the past. One of the residents stated if the fire alarms went off, they needed to exit the facility and not wait for staff. 1 out of 7 residents stated that on 1/7/25 during the fire was asked by staff to wait in the room for further instructions. 4 out of 7 residents confirmed they left with family members prior the evacuation taking place. Interviews with staff revealed facility staff became aware of the fire as some had observed the fire begin up in the mountain. Staff began warning residents in their rooms. Off duty staff were called to return to the facility and arrived shortly after. Between 7:30pm – 8:30pm staff began the evacuation process and assisted by knocking at residents’ rooms. They notified residents that they needed to evacuate. Staff carried or assisted residents down the stairs, assembling residents in the lobby. Staff were following fire department’s instructions. Administrator, Maintenance Director, Business Coordinator, Memory Care Director, and Wellness Director stated to have return to the facility at least three times to attempt to do another check of the building. (CONTINUED ON LIC 9099C) However, they were instructed by fire department not to enter the building and were notified by firefighters that the last resident was evacuated and was in an emergency service vehicle evacuating the area. Staff stated they did not receive an evacuation notification. Interview with Resident #2 (R2)’s responsible party revealed the facility had an evacuation plan in place and did evacuate residents from the facility safely prior to an evacuation order. Resident #1(R1)’s responsible party stated to have gone into the facility and evacuated their family member themselves. Per R1’s responsible party, R1 does not have cognitive impairment. Interviews were attempted with responsible parties for Resident #3 and #4(R3-R4) but were not successful. Interview with Pasadena Fire Department Fire Captain revealed that due to the circumstances, facility staff took measurements that were successful in the safety of all residents. LPA was unable to obtain records requested to Pasadena Fire Department and Los Angeles Sheriff Department. Although the allegation may have happened, there were no witnesses that observed the responsible party evacuating R1, at this time there is not enough evidence to support the allegation. LPA was unable to review service logs to establish a timeline of the process of evacuation and the respond time from the fire department. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Maria Quizon Administrator over the phone and a copy of this report was emailed for signature.the state’s words, verbatim · CDSS document, May 19, 2025 · control 28-AS-20250214161239

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to follow up on incident report submitted to the department on 11/19/24. LPA met with Maria Quizon and explained the reason for the visit. On 11/19/24, facility submitted incident report to report the following incident: On 11/18/24, staff heard a scream from Resident #1's(R1) room. When staff enter the room, staff observed Resident #2(R2) in R1's bedroom. R1 stated R2 had thrown a picture frame and hit R1. R1 was bleeding between the nose and forehead. Paramedics were called and R1 was taken to the hospital. Pasadena police department responded to the call with paramedics and provided report #CUS0135. Interviews conducted with staff revealed R2 has had aggressive behaviors towards staff. However, has not shown aggressive towards other residents. LPA attempted to interview R1-R2 but was unable to interview due to cognitive skills. R2 returned to the facility on 10/29/24 after being in skill nursing since July 2024. Documents reviewed revealed R2 has a history of aggressive behaviors. No incident reports were noted for aggressive behaviors between April - June 2024. Needs and care plan has been updated to note change in medication on 11/11/24. Facility staff updated sound device sensors in R1 and R2 bedrooms to increase awareness of the whereabouts of residents. Staff do hourly checks on R2 when R2 chooses to stay in bedroom and if R2 leaves the room staff are notify by the sound devices place near the bed and door and respond immediately. No deficiencies were noted during this visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 25, 2024

Allegation investigated: Facility staff did not provide information on resident’s injury. Staff are retaining residents that require a higher level of care.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Leticia Martinez and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of staff/resident roster. LPA reviewed files for six (6) resident files and requested copies of physician’s report, admission agreement, appraisal needs and service plan, incident reports. On 8/9/24 Administrator provided copies of R1’s file to the department. On 8/26/24 LPA interviewed 5 residents and delivered findings regarding the above allegations. The investigation revealed the following: Regarding allegation: Facility staff did not provide information on resident’s injury. It is alleged R1 sustained a fractured shoulder from a fall, but staff were unable to provide any details about the incident to the resident’s representative. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews conducted with staff revealed that on 12/27/23 at around 11:00pm staff responded to R1’s pendant call. Once staff arrived at the room, they found R1 seating in the floor, with blood dripping from the head. R1 stated to have hit the head. Staff assisted and notified R1 that they will contact 911. R1 refused medical care. However, staff contacted 911 per protocol and send R1 out to be evaluated. Staff stated they contacted the family to notify of incident and no additional information was requested after the initial contact. Documents reviewed revealed incident report dated: 1/10/24 was submitted to the department to report the incident occurred on 12/27/23 regarding R1’s fall and assistance provided. Per incident report R1’s family member was notified of incident on the same day. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are retaining residents that require a higher level of care. It is alleged facility’s staff retained R1 and several residents with dementia in the assisted living. Interviews conducted with management team revealed that there are currently 3 residents from assisted living with a dementia diagnosis and waiting for an opening in their dementia unit. Per administrator the dementia unit is full and has a waiting list from which the residents from the assisted living have priority. The three residents have been diagnosed with dementia within the last 8 months, and are either under care with a private caregiver or are under hospice services. Management staff spoke with R1’s responsible party regarding change in condition and R1’s need of higher level of care. Documents reviewed revealed 3 out of 7 residents’ physician’s reports note residents have a dementia diagnosis which was updated within the last 8 months as the diagnosis was not noted on their previous physician’s report. One of these residents is on hospice care, another has a private care giver, and the last one has a location device in place. Facility has set up hourly safety checks for the residents, they provide a concierge at the lobby to observe who enters and exits the facility, and a sound device is located in their doors to alert staff that the residents have exit the rooms. Even though there are residents with dementia in the assisted living the facility is taking precautions and following regulations to provide care for these residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2024 · control 28-AS-20240802160514

Type of visit: POC

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit at the facility to follow up on deficiency noted on 7/9/24. LPA met with Maria Quizon and explained the reason for the visit. On 7/9/24 LPA conducted a POC visit and on a case management visit noted the following deficiency: 87309 Storage Space: (a) On 6/6/24 LPA Flores conducted an annual visit and observed cleaning solution on resident's night stand in room #222 per physician's report resident has dementia. On 7/9/24 LPA conducted a POC visit and notices the cleaning solution on the same spot. Therefore, cited the deficiency during that visit. On 7/22/24 LPA toured room #222, cleaning solutions were removed, and obtained copies of resident's care plan regarding cleaning supplies and staff training. Deficiency cleared during this visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 22, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction(POC) visit at the facility to follow up on deficiencies noted on 6/6/24 during an annual visit. LPA met with Maria Quizon and explained the reason for the visit. On 6/6/24 LPA conducted an annual visit at the facility and noted the following deficiency: Type A - Section 87309(a) - Storage Space: On 6/6/24 LPA observed cleaning solution in room #222 were a resident with dementia resides. On 7/9/24 LPA observed room #222 and cleaning solutions were observed in the residents' night stand. Deficiency is being noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Maria Quizon and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 10, 2024

87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in LPA observed cleaning solution on 7/9/24 in room #222 were a resident with dementia resides which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: Administrator removed cleaning solutions during the visit, and will discuss and write a plan with family regarding maintaining any hazardous materials in the room and provide a copy, and provide training to staff regarding observing and reporting chemical in rooms of residents with dementia to the department by by POC due date 6/7/24.

Type of visit: POC

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction(POC) visit at the facility to follow up on deficiencies noted on 6/6/24 during an annual visit. LPA met with Maria Quizon and explained the reason for the visit. On 6/6/24 LPA conducted an annual visit at the facility and noted the following deficiencies: Type A - Section 87470(a)(1)(B)1 - Infection Control Requirements: On 6/6/24 LPA observed staff exited room #229 in which resident is in quarantine and did not use hand sanitizer or proper measure to prevent infection spread. On 7/9/24 LPA was provided copies of training provided to staff between June 8 - 12th on Hand washing for Safety and Infection. Deficiency cleared as of 7/9/24. Type A - Section 87303(e)(2) - Maintenance and Operation: On 6/6/24 LPA tested water temperature which tested as follow; room #118 at 122.8 degrees F., room #122 at 121.0 degrees F., room #308 tested at 97.5 degrees F. On 7/9/24 LPA measured water temperature in room #122 at 107.5 degrees F., room #308 at 117.0 degrees F., room #118 at 107.7 degrees F. Deficiency cleared as of 7/9/24. Type B - Section - 87470(b)(2) - Infection Control Requirements: On 6/6/24 LPA observed staff was providing care to a resident with a contagious disease and staff was not wearing PPE supplies. On 7/9/24 LPA obtained a copy of training provided between June 8 - 12th on Wearing PPE for Safety and Infection Control. Deficiency cleared as of 7/9/24. Type B - Section - 87618(b)(3)(E) - Oxygen Administration - Gas and Liquid: On 6/24/24 LPA observed oxygen tank was without a stand in room #118. On 7/9/24 LPA observed the oxygen tank was removed. Deficiency cleared as of 7/9/24. Exit interview was conducted with Maria Quizon and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced continuation annual visit at the facility. LPA met with Maria Quizon and explained the reason for the visit. On 6/6/24 LPA Flores conducted an initial annual visit. During today's visit LPA concluded the following domains from the CARE inspection tool: Finished Infection Control by reviewing training, emergency questions, and that staff have TB test clearance on file. Staffing, Personnel Records/Staff Training, Disaster Preparedness, Residents with Special Health Needs. LPA reviewed 6 staff files, Emergency Disaster Plan which was last reviewed on 4/2/24. Infection Control Plan was last reviewed on 2/16/24. Last disaster drill was conducted on 5/29/24 and are conducted within 1-3 months. Administrator certificate was observed for Maria Quizon #7002029740 exp. date: 9/28/25. A copy of liability insurance was obtain on 6/6/24. Interviews were conducted with 4 staff and 4 residents. No deficiencies were cited during this visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA Flores met with Maria Quizon and explained the reason for the visit. Facility is licensed to served 32 ambulatory residents and 80 non-ambulatory, of which 5 may be bedridden. First floor is cleared for bedridden and there is fire clearance granted for egress exits and fire alarm. There are no large bodies of water in the property. Facility is a 3 story building, with multiple activity/common areas, a commercial kitchen, and a memory care unit. Facility currently has 11 residents under hospice. LPA Flores conducted a tour of the facility with Maria Quizon and Maintenance Director and observed the following: Facility is in good repair indoor and outdoor. All common areas are in good repair with sufficient seating area. Environmental cleaning was observed. There are different fireplaces in the common areas which are cover with a glass door. Kitchen area was observed clean. Sufficient food was observed for at least 2 days of perishables and 7 days of non- perishables. Special diets were listed. A total of 7 resident rooms were randomly observed and each room was observed in good repair with sufficient lighting, the required furniture, and bedding supplies. Oxygen tank without a stand was observed in room #118. Cleaning solution was observed in room #222 in the night stand, resident has a dementia diagnosis and should not store cleaning solutions. Bathrooms were observed in each room, each has the required grab bars, and skid floor in the showers, and are in good repair. Shower in room #312 was observed with mole in the shower floor. Water temperature was tested between 97.5 - 122.8 degrees F., which is not within the required 105-120 degrees F. Fire alarm sprinkle system and fire extinguisher were observed throughout the facility and last checked on 1/3/24. Carbon Monoxide/Smoke detectors were tested and are in working condition. LPA tested alert button in random rooms and staff responded within 2 minutes. Facility provided shaded seating areas outdoors. Let us Know PUB 475, Local Ombudsman poster, and personal rights are posted by the mailboxes. Each stairwell has an evacuation chair on top of the stairwell. (CONTINUED ON LIC 809C) The facility currently has residents in quarantine due to an infection outbreak. LPA and administrator observed a staff exit room #229 which is under quarantine, red zone sign at the door and PPE cart outside. Staff was observed exiting without PPE equipment, no hand hygiene procedures were observed being perform after exiting the room. The facility has an egress system in place doors were tested and are in working condition. LPA reviewed medication and files for 7 residents. During this visit LPA completed the following domains of the CARE inspection tool: Operational Requirements, Physical Plan/Environment Safety, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports. LPA will return at a different time to finish the other domains. Deficiencies were noted today per Title 22 Regulations. Exit interview was conducted with Maria Quizon and a copy of this report, LIC 809D, and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 6, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility staff is restricting resident from seeing a visitor.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Teresita Villalvaso and explained the reason for the visit. Administrator arrived 20 minutes later. The investigation consisted of the following: LPA requested copies of staff and resident roster. LPA interviewed 7 residents and 5 staff and requested copies of visitor’s sign in log, and visitor’s policy notice for staff. The investigation revealed the following: Regarding allegation: Facility staff is restricting resident from seeing a visitor. It is alleged administrator will not let resident’s visitor, who is a past employee come and see the resident. Interviews with residents revealed that residents are aware of visiting policy and receive visitors at the facility. Visitations have not been restricted for any of the residents. 2 out of the 7 residents mentioned that they have been visit by former staff, who visit them, and they visit outside the lobby. (CONTINUED ON LIC 9099C) Unsubstantiated Per staff interviews, facility allows visitors for residents, unless they have a restraining order, and a particular person is not allowed to visit. Currently there are no unauthorized visitors for any of the residents. Staff may need to check with the residents, or power of attorney when there is a visitor that does not visit regularly to ensure residents desire to have the visitor and/or power of attorney are aware of who is visiting the residents. Per administrator former employees are welcome to visit the residents as long as the resident request the visit upon announcing the visitors to the residents and/or they requested the former employee to come. Administrator is aware that visitations cannot be restricted and accommodates the visits as needed. LPA reviewed visitor sign-in sheet from 3/1/24 to 3/20/24 there were a total of 430 visitors between those days. Resident's Visitors policy was observed as part of residents' admission agreement offering the opportunity for guest to visit and participate in activities. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Maria Quizon administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 28-AS-20240314134814

Allegation investigated: Questionable death. Staff are not preventing the spread of a communicable disease. Staff are not following proper hand washing.

Licensing Program Analyst (LPA) Tena Herrera made an unannounced subsequent complaint visit in response to the above-mentioned allegations. LPA met with Administrator Maria Quizon and explained the purpose of the visit. The investigation consisted of the following: During initial visit dated LPA Truman toured facility, obtained a copy of the Staff and Resident Roster, Special Incident Report's (SIR's), Resident Discharge Papers, Line Lists for Department of Public Health (DPH) and Resident Death Reports. No immediate health and/or safety concerns were noted during visit. During todays subsequent visit LPA Herrera obtained copies of Staff and Resident Rosters, Death Reports from months of Feb/March 2023, Department of Public Health clearance letter for Covid-19 and Gastrointestinal Illness from March 2023, incident reports from Feb/March 2023, weekly in-service training sign in sheets from March 2023, interviewed 10 Residents and 4 Staff. (CONTINUED ON 9099-C) Unsubstantiated The investigation revealed the following: Allegation: Questionable death. It is alleged that the facility had a Covid-19 and Norovirus outbreak during March 2023 and 2 residents died because of this outbreak. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that resident deaths during or around that time were not results of either outbreak. LPA reviewed all death reports from February and March 2023 and none of the death reports indicated that these deaths occurred because of Covid-19 or Norovirus/Gastrointestinal viruses, it was documented on the death reports that residents died because of natural causes and there was no other information provided specifying what resident passed and that it was due to facility neglect. Allegations: Staff are not preventing the spread of a communicable disease; Staff are not following proper hand washing. It is alleged that staff are not properly sanitizing or washing their hands to prevent the spread of Covid-19 and Norovirus. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegations and stated that during that time the Department of Public Health were visiting on weekly basis to verify proper sanitation was being practiced and encouraged with the residents; staff further stated that facility continues to sanitize, disinfect, practice and promote proper hand washing techniques. Interview with Staff #1 revealed that as a precaution facility continues to test residents and staff on a weekly basis. LPA reviewed in-service training and there were weekly infection control training's being conducted every week during the month of March and per staff these training's are still conducted on a regular basis. LPA received copies of the Department of Public Health clearance letters for Covid-19 and Gastrointestinal Outbreaks from March 2023. Interviews with residents 10 out of 10 residents denied the above allegations and stated that the facility is maintained clean and sanitized, and there are sanitizing stations all throughout the facility. LPA toured facility and observed sanitizing stations throughout hallways and common areas. Per Community Care Licensing records facility reported both outbreaks and clearance letters in a timely manner. Based on statements/interviews conducted with staff and residents, review of facility records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided Administrator Maria Quizon.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20230315163209

Allegation investigated: Staff do not treat resident with dignity and respect.

On 3/14/24 at 9:30 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced complaint visit to the facility. Upon arrival LPA met with Administrator Maria Quizon and explained the purpose of the visit. During today’s visit LPA toured the facility with Administrator. LPA obtained resident roster and staff roster. LPA conducted file review for S1 through S3. LPA also interviewed: Administrator and a total of two (5) staff who shall be referred to as S1 through S5. LPA interviewed a total of 10 residents who shall be referred to as: R1 through R10. Report continued on 9099c Unsubstantiated The investigation reveals the following: Regarding " Staff do not treat resident with dignity and respect”. It is alleged that S1 is rude and belittles the residents. The Administrator denied the allegation stating staff have never disrespected the residents and none of the residents complained about being disrespected. 5 out of 5 staff denied the allegation, stating they have never seen S1 or any staff disrespect or belittle the residents. 6 out of 10 residents denied the allegation, stating S1 never disrespected them, and they have not witnessed staff disrespect other residents. 4 out of 10 residents do not remember S1. LPA review staff files for S1 through S3 and did not observe disciplinary actions regarding the allegation. Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Maria Quizon and a copy of this record provided.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20240306155252

Allegation investigated: Resident developed a pressure injury due to staff neglect. Facility staff did not seek timely medical attention for resident in care. Staff did not notice a change in resident conditions.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met Maria Quizon with and explained the reason for the visit. The investigation consisted of the following: On 11/9/23 LPA Flores conducted a health and safety check, toured commercial kitchen, common areas, residents' rooms were not toured as facility has a COVID breakout. LPA requested the following documents for Resident #1 (R1); physician's report, admission agreement, identification and emergency information, medication sheet for November 2023, needs and service plan, facility's notes. Investigation Bureau Department (IB) investigator Peter Zertuche conducted interviews with 5 facility staff, wound care physician, and requested R1’s medical records. On 3/14/24 LPA Flores conducted interviews with 7 residents and 3 additional staff and delivered findings. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegations: Resident developed a pressure injury due to staff neglect, Facility staff did not seek timely medical attention to resident in care, and Staff did not notice a change in resident conditions. It is alleged R1 was diagnosed with unstageable wounds that developed at the facility for which R1 needed immediate hospitalization and facility staff did not notice the wound. On 10/31/23, R1 was visited at the facility by an occupational therapist. The occupational therapist had been providing services for movement and during the therapy noted the wound on the left heel. Occupational therapist informed facility staff and R1’s representative. R1’s representative contacted a wound specialist to evaluate R1. On 11/1/23, wound care doctor visited R1 at the facility and observed a 2cmx2.3cm sore on the left heel which was noted as “unstageable due to the presence of eschar covering the entire wound with no blood or drainage”. Wound care doctor recommended that R1 be taken to an “acute hospital for further evaluation”. R1 was taken to the hospital where the wound on the left heel was unstageable, measured at 3cmx3cm, and according to the physician the wound is at least Stage III, since it would take weeks to months for a wound to grow black eschar over the wound. Interviews with staff revealed facility’s caregivers, med-tech, memory care director, and wellness director were aware of R1’s change in condition. Staff stated to have notified R1’s representative after they had noticed redness in the left heel. Although staff did not provide a clear date of when it was noted, staff stated the wound was observed for about 2 weeks. Staff also stated to not be trained to take care of wounds or prevention of wounds. Documents reviewed revealed, on 9/2/23, R1 complained of leg pain and contacted R1’s representative. A house doctor visited R1 and no signs of wound were noted during that visit. Based on the documents reviewed and interviews conducted, the facility staff were aware that R1 had developed the wound on the left heel while providing assistance with showers and assistance with activities of daily living. Staff noticed the wound, reported it to management, and R1’s representative. However, facility staff failed to obtain medical attention for R1 for at least 2 weeks, resulting in R1 obtaining an unstageable wound which measured 3cmx3cm. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. (CONTINUED ON LIC 9099C) Regarding allegation: Facility staff do not provide resident basic laundry services. It is alleged R1's closet was seen with a basket full of dirty clothes and have not been washed. Interviews conducted revealed 6 out of 7 residents stated they do their own laundry and/or do not need assistance with laundry. 1 out of 7 residents stated that facility staff assist with laundry services once a week and does not have concerns. Interviews with staff revealed memory care staff provide laundry services for residents once a week and maintain a log of services. Documents reviewed revealed R1 received laundry services from 8/5/23 to 10/28/23 weekly by a caregiver. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Maria Quizon and a copy of this report was provided. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining wound while in care. Refer to LIC 421IM*** The issuance of an additional civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the serious bodily injury was due to neglect. Exit interview was conducted with Maria Quizon and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20231107162836

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Mar 15, 2024

Additional Personal Rights of Residents in Privately Operated Facilities: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure measurements were taken to prevent R1 from developing an unstageable wound on the left heel which poses an immediate risk to the persons health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Administrator will schedule training for staff on prevention, observation, and procedures upon observing wounds in residents by POC due date 3/15/24, and will submit a copy of log, training description and duration of training by 3/28/24. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining wound while in care. Refer to LIC 421IM***

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Mar 15, 2024

Prohibited Health Conditions : (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidency by: Based on interviews and documents reviewed licensee did not ensure R1 was provided medical care and not retained at the facility upon developing an unstageable wound on the left heel which poses an immediate risk to the persons health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Administrator will schedule training for staff on prevention, observation, and procedures upon observing wounds in residents by POC due date 3/15/24, and will submit a copy of log, training description and duration of training by 3/28/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 15, 2024

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure R1was provided medical care in a timely manner after developing a wound on the left heel which poses an immediate risk to the persons health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Mar 14, 2024

Plan of correction: Administrator will schedule training for staff on procedures, notifying responsible parties, and seeking medical care upon observing wounds in residents by POC due date 3/15/24, and will submit a copy of log, training description and duration of training by 3/28/24. ***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustaining wound while in care. Refer to LIC 421IM***

Allegation investigated: Resident's diapering needs are not being met. Staff mismanaged resident's money. Staff did not ensure facility is kept free of hazards.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced 10-day complaint visit regarding the above allegations. LPA met with Maria Quizon, Executive Director and explained the purpose of the visit. The investigation consisted of the following: LPA toured the facility focusing on the Memory Care unit common areas and hallways. LPA obtained copies of the Staff & Resident Rosters, Caregivers assignment sheets, Caregivers schedule, Charting notes and Altadena police report information (report #CUS0092, dated 03/01/2024). LPA conducted interviews with Staff #1 (S1) - Staff #8 (S8) and Resident #1 (R1) - Resident #8 (R8). Staff #9 (S9) was already off duty, therefore not interviewed. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation reveals the following: In regards to the allegation: “Resident's diapering needs are not being met.” It is alleged that the staff neglect on dressing patients and change for those incontinent residents, that incontinent residents don’t get changed every 1-2 hours which is mandatory and staff will wait until bed time. All the staff interviewed denied the allegation. Staff indicated that they have a regular routine and work assignments to follow. Staff stated that they do the rounds every 2 hours or 3x per shift or as necessary. Staff also indicated that they check with the residents throughout the day and before bed to ensure that the incontinent residents changing needs are being met. S1 stated that there is no reason to not change the residents diapers as they always have incontinent supplies available. S1 also stated that there was a police investigation on 3/01/2024 for similar allegations that has been concluded as police did not find any criminal activity. Interviewed residents denied the allegation and stated that staff are attentive to their needs and comply with what they ask for. The residents interviewed stated the staff check their diapers often and change them as needed and were staff never leave them sitting in soiled diapers. LPA reviewed documentation indicating that staff are doing their rounds as scheduled. During the tour, LPA observed sufficient incontinent supplies and did not observe incontinent odors in the facility, especially in the Memory Care unit. Documentation reviewed, interviews conducted with staff and residents and LPA observations do not corroborate this allegation. In regards to the allegation: "Staff mismanaged resident's money." It is alleged that staff have been hiding the truth to residents about money going missing, and theft from residents and staff member. All staff interviewed denied the allegation. Staff indicated that they do not handle cash resources for residents. Staff stated that there was no report or complaint about theft or missing money or items recently. Staff stated that the last time they heard of a complaint about missing items was years ago. Interviewed residents cannot corroborate the allegation. 8 out of 8 residents interviewed stated that they have never lost any money or valuable items and have not heard other residents having this issue. Residents indicated that they feel safe leaving items in their rooms. Staff interviews and resident interviews do not corroborate this allegation. ****CONTINUED ON LIC9099-C***** In regards to the allegation: "Staff did not ensure facility is kept free of hazards." It is alleged that staff ignore calls about safety hazards like moving items such as rugs or wheelchair from walk ways so patients won’t fall or trip. 8 out of 8 staff interviewed cannot corroborate the allegation. Staff stated that there was no falling or tripping incidents that happened in the facility in the recent months. Staff indicated that they discourage residents and their family to put rugs on top of their flooring due to safety hazard. Staff also indicated that residents always park their wheelchairs or walkers in their rooms or next to them in the dining area. S1 indicated that there was no recent report or complaint about safety hazards in the facility. 8 out of 8 residents interviewed denied the allegation. All residents interviewed stated that they feel safe in the facility and had never had any tripping or falling accident. Residents also indicated that they have not seen any obstruction in the hallway or common areas to cause them to trip or fall. During the tour, LPA did not observe any obstructions in the common areas or hallways. Staff interviews, resident interviews and observations do not corroborate this allegation. Based on statements and interviews conducted with staff, residents and review of facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Maria Quizon, Executive Director.the state’s words, verbatim · CDSS document, Mar 5, 2024 · control 28-AS-20240301100923

Allegation investigated: Lack of care and supervision resulted in multiple falls and an injury.

***** This report supersedes the original complaint investigation report dated 8/17/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.***** Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent unannounced complaint visit to supersede the report and deliver findings for the allegation listed above. LPA met with Maria Quizon, Administrator and explained the purpose of today's visit. During the initial televisit conducted by LPA David SIcairos on 05/06/21, LPA interviewed Staff #1 and obtained copies from Resident #1 (R1) file such as Identification And Emergency Info Sheet, Physician's Report, Resident Assessment, Preplacement Appraisal, Incident Reports, and Death Report. During the subsequent visit on 8/17/2022, LPA Sicairos interviewed Resident #2 - Resident #5 and Staff #1 - Staff #4. R1 was not interviewed as R1 passed away on 11/13/20. During today’s visit, LPA Bennette Pena conducted a tour of the facility’s common areas and Memory Care Unit. LPA delivered the superseded report that contained additional information with no changes to the findings.*****CONTINUED ON LIC9099-C***** Unsubstantiated ***** This report supersedes the original complaint investigation report dated 8/17/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.***** The investigation revealed the following: in regards to the allegation "lack of care and supervision resulted in multiple falls and an injury", it is alleged that R1 suffered multiple falls between June & July 2020 as a result of facility's lack of supervision and lack of communication amongst facility staff. R1 did not have a one-to-one caregiver while a resident of the facility. Interviews conducted with staff members denied the allegation. Staff members interviewed indicated that they will debrief each other during shift changes to make sure they are aware of what happened during the shift before theirs. Staff members indicated they utilize a communication binder and a whiteboard located in the medication room to keep track and log any changes in resident conditions. The communication binder contained community incident reports that were completed if there were incidents to be reported. Room checks were conducted every 2 hrs or as needed depending on the residents' needs. It was also indicated that the staff were aware of resident's falls and both the communication binder and whiteboard aided Caregivers in monitoring residents. LPA reviewed R1’s Resident Assessment Care Agreement (June 2020) showing personal Care Services and Care Plan under Memory Care (MC) unit. It indicated personal care for gait/balance and status checks due to having episodes and recent history of falls thus requiring safety status checks for fall prevention. Staff members interviewed indicated they do their best to keep residents from falling. Facility documented and reported R1's falls to Licensing. LPA reviewed the hospice records and community incident reports (Oct. 2020-Nov. 2020) regarding the resident’s falls which indicated that they were reported to Hospice, doctor, and Family member. Additionally, the reports indicated that there were no falls that led to injury that needed hospitalization and/or need to relinquish Hospice Services for Hospitalization. Facility also sought timely medical attention for R1 after her falls. Residents interviewed also denied the allegation. Residents interviewed indicated that they are happy with facility staff and the services they receive at the facility. LPA also reviewed the death report submitted to CCLD on 11/18/2020 indicating that a family member was notified on 11/13/20 at 3:45am of resident’s passing. During the tour of the Memory Care Unit, LPA observed (1) Med Tech and (2) Caregivers on duty. The staff to resident ratio at the MC Unit is to 5-7 Residents for all shifts; AM shift (6am-2pm), PM shift (2pm-10pm) and NOC shift (10pm-6am+1). Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Maria Quizon, Administrator.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 28-AS-20210428080720