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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200161
Report Date: 03/08/2024
Date Signed: 03/08/2024 01:09:50 PM

Document Has Been Signed on 03/08/2024 01:09 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:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Lucia AlviarTIME COMPLETED:
01:30 PM
NARRATIVE
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On this day at around 10:20 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Dympha Jimenez. LPA explained to Jimenez the purpose of visit. The Administrator Lucia Alviar (Administrator cert# 6004742735 expiration 7/7/2025) arrived at the facility at around 10:55am. .

During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining, garage and outside areas. The facility is a Level 4i home vendorized by the Regional Center of the East Bay (RCEB). LPA observed a fire extinguisher in the kitchen that appeared full and was last serviced on 11/7/2023. Smoke detectors and carbon monoxide detectors were tested and observed functional. There were sufficient supply of both perishable and non perishable foods. The facility has ample supply of warm blankets, sheets and towels available for use of the clients. First aid kit was inspected and observed complete and updated. Medications were observed locked in a cabinet in the family room. Hot water measured at 115 degrees Fahrenheit.

LPA reviewed 4 staff and 4 client files. All staff were observed fingerprint cleared and associated to the facility. Staff have current First Aid and CPR training. P&I money and log were reviewed. LPA observed the facility has sufficient amount of surety bond to cover amount of money being handled at one time.
The facility's last fire drill was conducted on 2/20/2024 and last earthquake drill was completed on 1/8/2024.
LPA reviewed medications and Medications Administration Records(MAR) with the Administrator.

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 03/08/2024
NARRATIVE
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While conducting client file reviews, LPA observed C4's ambulatory status is bedridden. The facility has an approved fire clearance for 6 non ambulatory clients.

LPA interviewed 2 staff and attempted to interview the client present. All the other clients were in their respective day program during the visit.

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

Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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Document Has Been Signed on 03/08/2024 01:09 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 03/08/2024 at 12:53 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: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record record conducted, the licensee did not comply with the section cited above in having a bedridden client which poses an immediate health, safety or personal rights risk to persons in care. The facility does not have a bedridden fire clearance.
POC Due Date: 03/08/2024
Plan of Correction
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The Administrator notified Fire Department about the bedridden fire clearance and submitted to LPA the following records:
request for a bedridden fire clearance, Lic 200 and facility sketch.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


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