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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191200037
Report Date: 01/29/2021
Date Signed: 02/02/2021 04:14:52 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: 53DATE:
01/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Jeanine Hernandez - Leasing DirectorTIME COMPLETED:
03:00 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 visit was conducted telephonically with Jeanne , the facility assistant administrator.

During the course of daily call status, LPA Flores has not receive facility's Line List, document with daily COVID 19 updates, such as new positive cases for residents and staff, deaths, hospitalization, test dates, etc., and/or an LIC 624 Incident Report, LIC 624A Death Report between the dates of 1/1/21 to 1/29/21.

Per Title 22 California Regulation Code Chapter 8 Division 6; 87211 Reporting Requirements; Facility is to report the department of any deaths, and/or any incident that threatens the welfare of the residents in written within 7 days of the occurrence.

See LIC 809D for deficiencies.

Exit interview was conducted via telephone with 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: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
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 2
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: 01/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2021
Section Cited

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87221 ReportingRequirements;...(a) licensee shall furnish... (1)A written report ...submitted to the licensing agency... within seven days of the occurrence of any of the events... (A) Death of any resident from any cause regardless of where the death occurred... This requirement is not met as evidience by:
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Based on daily calls and reviews facility has not submitted LIC 624A, and/or Line List with COVID 19 daily updates bewteen 1/1/21 and 1/29/21.
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Type B
02/12/2021
Section Cited

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87211 Reporting Requirements;.. (a) licensee shall furnish... (1) A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidende by:
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Based on daily calls and reviews facility has not submitted LIC 624, and/or Line List with COVID 19 daily updates bewteen 1/1/21 and 1/29/21.
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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: 01/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2021
LIC809 (FAS) - (06/04)
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