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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191200037
Report Date: 01/26/2022
Date Signed: 01/26/2022 03:27:09 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: 60DATE:
01/26/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Jeanine Hernandez - Assistant AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit to follow up on initial COVID 19 positive cases reported to the department on 1/21/22. LPA Flores met with Jeanine Hernandez Assistant Administrator and explained the reason for the visit.

On 1/21/22 LPA Flores contacted the facility to follow up on email dated 1/20/22 noting a possible COVID breakout at the facility. LPA Flores spoke on the phone with Administrator Anabelle Argenal who reported the breakout on 1/21/22. Facility's first COVID positive test result date was 12/26/21, administrator was made aware on the same date, 6 COVID positive test results occurred between 12/26/21 - 12/31/21 and 8 positive test results were received by administrator between 1/1/22 - 1/20/22 after facility conducted testing. Administrator stated that due to the breakout at the facility, was only able to reported to Pasadena Department of Public Health and did not follow up to report other pertaining agencies (Community Care Licensing Division (CCLD)and Local Ombudsman (LTCO)). Incident Report reporting COVID positive cases was faxed to the department on 1/21/22, there are no other methods of notifications to the department on record. Facility has continue to report daily since 1/21/22 of new cases.

Per Title 22 Regulations Chapter Division 6 Chapter 8 - Section 87211 Reporting Requirements - Facilities are to notify the department within 24 hours of occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors.

Deficiencies have been noted on LIC 809D.

Exit interview was conducted with Jeanine Hernandez assistant administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022
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: 01/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2022
Section Cited

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87211 Reporting Requirements:(a)...licensee shall furnish...reports as the Department ...require,...:(2)Occurrences, such as epidemic outbreaks,... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile... This requirement is not met as evidence by:
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Based on documents reviewed, and observation licensee failed to report CCLD, LTCO of COVID 19 cases prior 1/21/22 which poses a potential health, safety, or personal rights risk to 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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2022
LIC809 (FAS) - (06/04)
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