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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191200037
Report Date: 06/17/2024
Date Signed: 06/17/2024 02:11:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2024 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240612113615
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: 84DATE:
06/17/2024
UNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Jacqueline Hernandez - Business Services DirectorTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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9
Staff did not arrange medical care for a resident
Staff did not ensure that facility was maintained sanitary
Staff did not safeguard a resident's ambulatory devices
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Jacqueline Hernandez and explained the reason for the visit.

The investigation consisted of the following: LPA requested a copy of resident and staff roster. LPA conducted a tour resident #1’s room. LPA conducted interviews with 4 residents and 6 staff. LPA requested the following copies for resident #1 (R1); admission’s agreement, physician’s report, personal property and valuables, identification and emergency information sheet, incident report, notice to physician, preplacement appraisal information, and work orders. Copies of in-service training provided on 6/13/24 were obtained.

The investigation revealed the following: Regarding allegation: Staff did not arrange medial care for a resident. It is alleged R1 fell and sustained injuries however, staff did not call 911 for the resident. Per incident report, on 6/3/24 R1 was found in R1’s room in the floor around 6:45pm. Med Aide notified family member of fall and action taken. (CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 28-AS-20240612113615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: REGENCY PARK OAK KNOLL
FACILITY NUMBER: 191200037
VISIT DATE: 06/17/2024
NARRATIVE
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However, did not contact emergency respond until family member arrived at around 9:00pm and requested to arrange ambulance transport for R1. Interviews conducted revealed the following, per administrator it is protocol to contact 911 after a resident sustains a fall and complaints of pain. Administrator and wellness director had a corrective action conversation with Med-Aide on duty the day of the incident as med-aide should have called 911 after assessing, checking, and observing resident was in continuous and severe pain. Per staff interview it was reported and observed that R1 was complaining of a lot of pain after the fall and 30 minutes after when checked. Med Aide failed to call 911 or arrange emergency transport after checking the resident self and observing R1 was still in pain. On 6/13/24, Administrator provided an in-service training on “procedure review/medical emergencies/criteria/conditions when to call 911.” Per one of the criteria listed in the in-service training pamphlet provided, “The community summons emergency medical services by calling 911 when the resident exhibits signs and systems of distress… fall with… severe pain…” Per administration a write up will be provided to Med Aide upon returning to work. Per the interviews with staff R1 was demonstrating severe pain and Med Aide fail to contact 911. Therefore, the allegation is substantiated.

Based on LPAs interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Regarding allegation: Staff did not ensure that facility was maintained sanitary. It is alleged there was fecal matter on the resident's bedroom furniture and on carpet. LPA observed R1’s room and observed the room was empty, the carpet looked cleaned with three brown half a dollar coin size stains and strong odor of what could be feces or urine. Per interviews conducted with staff R1 was assisted to clean self after toileting due to cognitive skills. Staff stated to find feces in the floor and/or wall in the morning constantly which were cleaned by staff during the day. Per records reviewed a work order was placed to clean the carpet on 4/16/24 and was completed on 5/13/24. Although the staff stated to clean the stains during the day. Due to interviews, LPAs observation and work order to clean the carpet completed in almost a month the allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.
(CONTINUED ON LIC 9099C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20240612113615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: REGENCY PARK OAK KNOLL
FACILITY NUMBER: 191200037
VISIT DATE: 06/17/2024
NARRATIVE
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Regarding allegation: Staff did not safeguard a resident’s ambulatory devices. It is alleged resident's wheelchair become lost on 6/3/2024 and found on 6/11/2024. Interviews conducted reveal the following: Per administrator, the wheelchair was place at storage and wellness director was aware of the location of the wheelchair. Per Wellness director, once the family inquired about R1’s wheelchair, staff began to search for the wheelchair. Family provided serial number and wellness director searched throughout the facility until it was found in the facility’s weight room. Wellness director was not aware of the family bringing in the wheelchair or of its where about and it is not certain how the wheelchair was place in that room. Document review revealed resident personal property and valuables was blank and had no items listed for R1. Per interviews conducted the facility staff were not aware that R1 had a wheelchair and were only aware of its location once wellness director search for the wheelchair. Therefore, this allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Anabelle Argenal and a copy of this report, LIC 9099D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20240612113615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2024
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...
This requirement is not met as evidence by:
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Administrator provided in service training regarding Emergency procedures on 6/13/24 to staff. Deficiency cleared as of 6/17/24.
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Based on interviews conducted licensee did not ensure that staff would call 911 for R1 after sustaining a fall and complaining of pain which poses an immediate risk to the health, safety, or personal rights of the residents in care.
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Type B
07/02/2024
Section Cited
CCR
87217(b)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidence by:
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Administrator will provide an in-service training to maintenance and housekeeping staff regarding proper cleaning and disinfecting and response time to fecal/urine carpet cleaning by POC due date 7/2/24.
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Based on observations and interviews conducted licensee did not ensure R1's room was sanitary at all times which poses a potential health, safety, or personal rights risk to the persons in care.
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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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20240612113615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2024
Section Cited
CCR
87217(b)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents'..., personal property... which have been entrusted to the licensee or facility staff.
This requirement is not met as evidence by:
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Administrator will certify in writing that upon admission all items will be listed, staff will be responsible to report items that may be found around the facility, and family will be notify of storage of such items by POC due date 7/2/24.
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Based on interviews and documents reviewed the licensee did not ensure that R1's wheelchair was properly listed and safe keep at the facility which poses a potential risk to the health, safety, or personal rights of the persons in care.
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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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2024 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20240612113615

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: 84DATE:
06/17/2024
UNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Jacqueline Hernandez - Business Services DirectorTIME COMPLETED:
02:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that resident’s ambulatory device were accessible to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Jacqueline Hernandez and explained the reason for the visit.

The investigation consisted of the following: LPA requested a copy of resident and staff roster. LPA conducted a tour resident #1’s room. LPA conducted interviews with 4 residents and 6 staff. LPA requested the following copies for resident #1 (R1); admission’s agreement, physician’s report, personal property and valuables, identification and emergency information sheet, incident report, notice to physician, preplacement appraisal information, and work orders. Copies of in-service training provided on 6/13/24 were obtained.

Regarding allegation: Staff did not ensure that resident’s ambulatory device was accessible to the resident. It is alleged facility staff did not ensure R1 had assess to walker because many times, R1 would be in one place however, the walker would either be in the dining room, or another resident would be using R1’s walker. Per interviews conducted with staff, due to R1’s cognitive skills, R1 would get up and walk without the walker. (CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20240612113615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: REGENCY PARK OAK KNOLL
FACILITY NUMBER: 191200037
VISIT DATE: 06/17/2024
NARRATIVE
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However, staff will follow R1 or prompt R1 to use the walker right away. Staff stated that as soon as they will notice R1 was up, a staff will follow right after to provide the walker, while in the common areas. Interviews with residents did not provide information regarding the allegation due to residents’ cognitive skills. Documents review revealed R1’s preplacement appraisal information sheet dated 4/10/24 notes R1 uses a walker and is ambulatory. Per appraisal needs and service plan dated 4/19/24, R1 needs constant reminders to use walker.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Anabelle Argenal and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7