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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191200037
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:51:54 PM

Document Has Been Signed on 05/16/2024 03:51 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:REGENCY PARK OAK KNOLLFACILITY NUMBER:
191200037
ADMINISTRATOR/
DIRECTOR:		ANABELLE ARGENALFACILITY TYPE:
740
ADDRESS:255 SOUTH OAK KNOLLTELEPHONE:
(626) 578-1551
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 206CENSUS: 82DATE:
05/16/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:36 AM
MET WITH:Annabelle Argenal - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:06 PM
NARRATIVE
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Licensing Program Analysts (LPA)s Mary Flores and Daniel Konishi conducted an unannounced annual visit at the facility to conclude annual visit started on 5/9/24. LPAs met with Annabelle Argenal and explained the reason for the visit.

During this visit LPAs concluded the following CARE inspection tool domains:
Infection Control, Operational Requirements, Staffing, Personnel Records/Staff Training, Disaster Preparedness, Residents with Special Health Needs.

LPAs reviewed the following during today's visit.
Eight (8) staff files. Training was reviewed and staff #3 - #8 do have a total of 20 hours which include hours on hospice, postural support, restricted health conditions, and dementia care. Except for staff #6.
Infection Control plan last updated on 5/1/24.
Emergency Disaster plan last updated on 6/2/23.
A copy of Liability Insurance was provided during the visit of 5/9/24.
Hospice plans and files were reviewed during the visit of 5/9/24.
Last Fire Drill was conducted on 3/26/24.

Administrator certificate was observed for Annabelle Argenal #6034626740 exp. date: 4/21/25.

Interviews with 4 staff and 4 residents were conducted.

Deficiencies were noted during this visit per Title 22 Regulations. Technical Violations were noted.

Exit interview was conducted with Annabelle Argenal and a copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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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Document Has Been Signed on 05/16/2024 03:51 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/16/2024 at 03:31 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
, 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: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 8 staff, staff #3-#8 (except staff#6) do not have 20 hours of training including the topics above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Administrator will submit copies of training provided to staff for a total of 20 hours including the above topics to the department by POC due date 5/30/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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