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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600627
Report Date: 03/09/2024
Date Signed: 03/09/2024 06:26:32 PM

Document Has Been Signed on 03/09/2024 06:26 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:REGAL HOMESFACILITY NUMBER:
015600627
ADMINISTRATOR:LUYON, REGINAFACILITY TYPE:
735
ADDRESS:24857 2ND STREETTELEPHONE:
(510) 299-4923
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 4CENSUS: 4DATE:
03/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Regina Luyon/Administrator TIME COMPLETED:
06:30 PM
NARRATIVE
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At 2:00 p.m. on this day, March 9, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection and met with staff, Jina Sunien, and informed the reason for visit. LPA called and spoke over the phone with Regina Luyon, administrator. Administrator arrived after about 30 minutes.

Facility has LIC9282 Infection Control Plan.

LPA toured the facility inside out with Jina Sunien. LPA inspected the living room, dining area, kitchen, bathroom, residents room, activty room, front, side and backyard. Food were checked and observed supplies of 2 days of perishables and 7 days of non-perishables.

Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in the bathrooms were tested and measured at 110.9 degrees Fahrenheit. Facility conducts disaster drills at least quarterly with fire drills last conducted 3/04/24. Fire extinguisher checked, observed fully charge with receipt showing purchased on 10/20/23.

LPA reviewed 5 staff and 4 residents files, and interviewed 2 residents and 2 staff. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Records, and doctor's orders. Resident's P&I checked and compared with last recorded balance.



.....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: REGAL HOMES
FACILITY NUMBER: 015600627
VISIT DATE: 03/09/2024
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LPA observed the following:
-at 2:22 p.m., no side fence on one side of the yard. According to staff it was knocked down during January 2024 storm which LPA confirmed with the administrator.
-at 5:00 p.m., fill dates on the medication labels on resident (R3) medications do not match the date listed on LIC622 Centrally Stored Medication and Destruction Record.

LPA obtained copies of the following updated/current documents on this same day:
1. LIC500 Personnel Report
2. LIC610D Emergency Disaster Plan
3. Proof of Surety Bond coverage

Administrator to submit copy of updated/current LIC308 Designation of Facility Responsibility by March 23, 2024.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/09/2024 06:26 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 03/09/2024 at 06:00 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: REGAL HOMES
FACILITY NUMBER: 015600627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

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 fill dates on the medication labels on resident (R3) medications do not match the date listed on LIC622 Centrally Stored Medication and Destruction Record. which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 03/23/2024
Plan of Correction
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Administrator to make corrections, and submit proof by 3/23/24.
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 not having side fence which poses a potential safety and/or personal rights risk to persons in care.
POC Due Date: 04/06/2024
Plan of Correction
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Administrator to obtain an estimate, and have the fence installed. Picture to be submitted by 4/06/24.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2024


LIC809 (FAS) - (06/04)
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