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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200161
Report Date: 02/14/2025
Date Signed: 02/14/2025 03:55:52 PM

Document Has Been Signed on 02/14/2025 03:55 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/
DIRECTOR:		LUCIA ALVIARFACILITY TYPE:
735
ADDRESS:3285 SANTA ROSA COURTTELEPHONE:
(510) 400-3952
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 4CENSUS: 4DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Andrew AlviarTIME VISIT/
INSPECTION COMPLETED:
04:15 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 this day at around 1:05pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Lydia Sugui. LPA explained to Sugui the purpose of visit. The Administrator Lucia Alviar (Administrator certificate# 6004742735 expiration 7/7/2025) was informed about the purpose of the visit. Andrew Alviar was authorized by the Administrator to sign the report.
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 1/6/2025. 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. Hot water measured at 112 degrees Fahrenheit.

At 1:29 pm, 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.

At 1:55 pm, P&I money and log were reviewed with DSP Andrew Alviar. 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 1/22/2025 and last earthquake drill was completed on 10/22/2024. continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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 6
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: 02/14/2025
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
At around 2:40 pm ,LPA reviewed medications and Medications Administration Records(MAR).

The following deficiencies were observed:
  • At around 1:10pm, LPA observed cleaning chemicals unlocked in the cabinet under the sink.
  • At around 1:25pm, LPA observed medication cabinet was unlocked.
  • C4 has Type 2 diabetes and blood sugar check. Staff checks C4's blood sugar without training from a skilled professional

Deficiencies were 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.

The following forms were requested to be sent to CCL by Tuesday, February 18, 2024:
  • Infection Control Plan
  • Lic 500
  • Client Roster
  • Disaster Plan
  • Liability Insurance
  • Vehicle registration, insurance and driver's license of staff transporting clients



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: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/14/2025 03:55 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/14/2025 at 03:34 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: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 cleaning chemicals unlocked in a cabinet under the sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
1
2
3
4
Staff locked all chemicals during the visit. This deficiency is cleared.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 having medication cabinet locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
1
2
3
4
Medicine cabinet was locked during the visit. This deficiency is cleared.
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: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/14/2025 03:55 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/14/2025 at 03:34 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: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80092.1(a)
General Requirements for Restricted Health Conditions
(a) A client with a restricted health condition specified in Section 80092 may be admitted or retained in an adult CCF if all requirements in Sections 80092.1(b) through (o) are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviews and interviews conducted the licensee did not comply with the section cited above in retaining C4 who is diabetic but unable to check own blood sugar which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
1
2
3
4
The Administrator has notified RCEB about C4's need for a licensed professional to check blood sugar and will update LPA 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/14/2025 03:55 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 02/14/2025 at 03:34 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: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1507(c)(1)(D)
General Provisions
(D) Facility staff shall be trained by the identified health care professional practicing within his or her scope of practice who shall monitor, according to the individualized health care plan, the staff's ability to provide incidental medical services and who shall review, correct, or update facility staff training as the health care professional deems necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on file review conducted, the licensee did not comply with the section cited above in not having staff undergo training with a licensed professional for C4's diabetes maagement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
1
2
3
4
By POC date, Administrator states all staff will undergo training with a licensed professional regarding C4's diabetes management and submit proof to CCL 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6