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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191200037
Report Date: 01/08/2021
Date Signed: 01/11/2021 04:16:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:REGENCY PARK OAK KNOLLFACILITY NUMBER:
191200037
ADMINISTRATOR:ANABELLE ARGENALFACILITY TYPE:
740
ADDRESS:255 SOUTH OAK KNOLLTELEPHONE:
(626) 578-1551
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY:206CENSUS: DATE:
01/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:52 PM
MET WITH:David Lopez - Business Office ManagerTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted a case management visit with the above facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management visit was conducted telephonically with David Lopez, the facility's person in charge.

During the course of daily status calls made to the facility, LPA Flores was informed that administrator record was not present at the facility as of 12/18/20.

Per Health and Safety Code 1569.619 a certify administrator must be present to monitor day to day operations to ensure the health and safety of the residents.

See LIC 809D for deficiencies.

Exit interview was conducted via telephone with David Lopez a copy of this report and 809D was email for review and signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY PARK OAK KNOLL
FACILITY NUMBER: 191200037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/11/2021
Section Cited

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1569.618 Administration and management of residential care facilities;... (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours...
This requirement is not met as evidence by:
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Designated Administrator has not been present at the faciltiy as of 12/18/20. In addition a person in charge with proper certification has not been assigned or notify in writing to the department.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2021
LIC809 (FAS) - (06/04)
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