<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200161
Report Date: 08/12/2022
Date Signed: 08/12/2022 11:39:04 AM

Document Has Been Signed on 08/12/2022 11:39 AM - 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:REGENCY CARE HOMEFACILITY NUMBER:
019200161
ADMINISTRATOR:LUCIA ALVIARFACILITY TYPE:
735
ADDRESS:3285 SANTA ROSA COURTTELEPHONE:
(510) 489-2101
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
08/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Minda Nacu, CaregiverTIME COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/12/2022 at 10:00AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Minda Nacu, Caregiver. Caregiver called Administrator and LPA explained the purpose of the visit. Administrator, Lucia Alviar gave approval for Caregiver to sign documents.

Upon entry, Staff tried to take LPA's temperature, but was unsuccessful. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 96.7 degrees Fahrenheit. Fire extinguisher last serviced on 10/25/2021. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors log and temperature log for both clients and staff. LPA observed clients temperatures were checking this morning. LPA observed facility has a copy of the Mitigation Plan on file. LPA observed food and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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 4
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: REGENCY CARE HOME
FACILITY NUMBER: 019200161
VISIT DATE: 08/12/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809.

The following deficiency was observed:

-At 10:42AM, LPA observed 2 washing machines, 2 dryers, 1 plastic bin, and a chair in the back yard on right side of house.

LPA request the following documents to be submitted to CCLD by 8/19/2022.

LIC500 Personnel Report
LIC308 Designation of Administrative Responsibility
LIC610D Emergency Disaster Plan

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/12/2022 11:39 AM - It Cannot Be Edited


Created By: Laura Hall On 08/12/2022 at 11:26 AM
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: REGENCY CARE HOME
FACILITY NUMBER: 019200161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
80087 Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having 2 washer, 2 dryers, a chair, and plastic storage bin free from passageway which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2022
Plan of Correction
1
2
3
4
Administrator agreed to remove items and make passageway free of obstruction and submit a photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4