019200161-2-15-2023-15-AS-LFII-CP42BT-20230215161540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200161
Report Date: 02/15/2023
Date Signed: 02/15/2023 04:15:49 PM

Document Has Been Signed on 02/15/2023 04:15 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:	REGENCY CARE HOME		FACILITY NUMBER:	019200161
ADMINISTRATOR:	LUCIA ALVIAR		FACILITY TYPE:	735
ADDRESS:	3285 SANTA ROSA COURT		TELEPHONE:	(510) 400-3952
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY: 6		CENSUS: 4	DATE:	02/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Care Staff-Ugale, Remedios		TIME COMPLETED:	04:25 PM

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 2/15/2023, at 2:55 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by Care staff, Ugale, Remedios and explained the purpose of todays visit. During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All sharps and toxins were locked up and inaccessible to clients in care. Common areas are disinfected 4 times throughout the day or as needed. Fire extinguisher was last serviced on 10/25/2022. Facilities room temperature is maintained at 69 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are functional. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care. During record review, LPA observed facility has a copy Disaster Plan on file. Facilities Infection Control Plan will be sent via email to LPA. Continue on Lic809-C

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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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Document Has Been Signed on 02/15/2023 04:15 PM - It Cannot Be Edited

Created By: Liridon Fici On 02/15/2023 at 03:47 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: REGENCY CARE HOME	FACILITY NUMBER: 019200161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). 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 not maintaining hot water temperature in common use bathroom for clients to use, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2023
	Plan of Correction
1 2 3 4	Administrator agreed to adjust hot water temperature to reflect Title-22's regulation and to submit a photo as proof to CCL by POC due date.

Type A

Section Cited

CCR

80020(a)

Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by not having room 3 on the facility sketch cleared by fire department and utilizing room 3 for personal use, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2023
	Plan of Correction
1 2 3 4	Administrator agreed to get fire clearance for room 3 on the facility sketch for administrator to use as personal use and to submit approval to CCL by POC due date.

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:

Yvonne Flores-Larios

LICENSING EVALUATOR NAME:

Liridon Fici

LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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: REGENCY CARE HOME	FACILITY NUMBER: 019200161
	VISIT DATE: 02/15/2023

NARRATIVE

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Continue from Lic809

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

At 3:15PM, LPA measured and observed the hot water temperature is at 127.5 Degrees F in common area bathroom.

At 3:20PM, LPA observed room 3 on the facility sketch is locked and not cleared by fire department to be utilized by facilities administrator or other staff personnel.

Exit interview conducted with care staff, and a copy of this report provided along with appeal rights.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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