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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200161
Report Date: 02/15/2023
Date Signed: 02/15/2023 04:34:49 PM

Document Has Been Signed on 02/15/2023 04:34 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 HOMEFACILITY NUMBER:
019200161
ADMINISTRATOR:LUCIA ALVIARFACILITY TYPE:
735
ADDRESS:3285 SANTA ROSA COURTTELEPHONE:
(510) 400-3952
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
02/15/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
04:24 PM
MET WITH:Care Staff-Ugale, RemediosTIME COMPLETED:
04:40 PM
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On 2/15/2023, at 4:24PM, Licensing Program Analysts (LPA) L. Fici conducted an Annual Infection Control Inspection and assessed an civil penalty in the amount of $500.00, however, LPA did not indicate the civil penalty on the annual inspection visit.

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