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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191200037
Report Date: 03/10/2022
Date Signed: 03/11/2022 07:45:44 AM


Document Has Been Signed on 03/11/2022 07:45 AM - It Cannot Be Edited

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: 61DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Jeanine Hernandez, Assistant AdministratorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Jeanine Hernandez, Assistant Administrator and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. The facility cares for elderly residents and is allowed to have 10 hospice residents. There are currently 5 residents on hospice.

Resident bedrooms were randomly chosen for review. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was between 110.1 - 114.6 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the dining room, patio, library, TV room, activity room and coffee parlor. These areas are clean and have the required furniture. The patio area has a water fountain with a fence around the entire perimeter to keep dementia residents safe. There is a screening station at the entrance of the building where staff screen all visitors for COVID-19.

LPA reviewed 6 resident files to confirm emergency contact is updated and residents have health screenings on file. 6 staff records were reviewed to confirm health screenings, training and fingerprint clearances. LPA reviewed 6 residents' medications. Medications are documented properly and stored in a locked medication cart.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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