191200037-4-10-2025-28-AS-MGFS-DFLUM3-20250410154140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191200037
Report Date: 04/10/2025
Date Signed: 04/10/2025 03:42:02 PM

Document Has Been Signed on 04/10/2025 03:42 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 KNOLL		FACILITY NUMBER:	191200037
ADMINISTRATOR/ DIRECTOR:	ANABELLE ARGENAL		FACILITY TYPE:	740
ADDRESS:	255 SOUTH OAK KNOLL		TELEPHONE:	(626) 578-1551
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY: 206		CENSUS: 90	DATE:	04/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:37 AM
MET WITH:	Jacqueline Hernandez - Business Services Director		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst(s) (LPA)s Mary Flores and Blanca Gonzalez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Jacqueline Hernandez Business Services Director and explained the reason for the visit. Facility is licensed to served 206 elderly residents age 60 and over, ambulatory and non-ambulatory. Rooms excluded from non-ambulatory status are #110, 221, 222, 243. The facility is a two story building located in a residential neighborhood. It consist of several resident bedrooms in both floors, a lobby seating area, offices, a dining room, a coffee bar, a studio dining room, a commercial kitchen, a medication room, a common shower, an activity room, a family room, a parlor, a courtyard in the first floor, a conference room, a TV room, a library, a laundry room, and patio in the second floor. LPA reviewed the following CARE inspection tool domains during this visit: Infection Control: Infection control plan was reviewed which meets current regulations and was last revised on 5/12/24. Hand sanitizer and proper sanitation were observed during the visit throughout the facility. There is a responsible person and emergency training was provided to staff. Personal protective equipment was observed. Staff have a TB test clearance on file. Operational Requirements: Facility maintains a plan of operation. Facility has a current liability insurance. Facility is operating within the license. Physical Plant/Environmental Safety: LPAs conducted a tour of the facility with Jacqueline Hernandez and observed the following: Facility was observed clean and in good repair indoors and outdoors. (CONTINUED ON LIC 809C)

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
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: 04/10/2025

NARRATIVE

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First Floor: Lobby, family room, TV room, dining room, coffee bar, beauty parlor are clean and in good repair. Fireplace was observed in the lobby and it was adequately screened. Kitchen was observed clean, with hot water temperature warning sign. Emergency food supplies were observed in a closet by the kitchen. Wellness room was observed inaccessible to the residents. Common shower across from the elevator has skid flooring. Four resident bedrooms were observed in the first floor, each with sufficient lighting, required furniture and bedding supplies. The residents bathrooms were clean and in working condition with grab bars, and skid mats. Water temperature was tested between 108.8-112.4 degrees F.
Second Floor: Library's fireplace is adequately screened. Library, conference room, and sensory room were observed clean and in good repair. Five resident bedrooms were observed in the second floor, each with sufficient lighting, required furniture and bedding supplies. The residents bathrooms were clean and in working condition with grab bars, and skid mats. Water temperature was tested between 105.0 - 113.5 degrees F., which is within the required 105-120 degrees F.
Passageways were clear of obstructions. Courtyard has shaded seating area for residents.
Staffing: Administrator Anabelle Argenal arrived at the facility shortly after. At least one person on shift has current CPR/First Aid training on file. There are 4 available night staff, whom have been provided emergency training. Sufficient staff were observed.
Personnel Records/Staff Training: Administrator certificate for Anabelle Argenal #6034626740 was observed exp. date: 4/21/25. All staff records were available for review. LPA reviewed a total of 4 staff files which included medical assessment, TB clearance, background clearance, and training. Staff training files were reviewed, training has been provided on Hospice, Restricted Health Conditions, and Postural. As well as dementia, emergency, and activities of daily living.
Resident Rights/Information: Personal Rights, Let Us No poster (PUB 475), and Local Ombudsman posters were observed in the lobby.
Planned Activities: Activity materials were observed, for activities such as religious, clubs, exercises, and gardening. Outdoor area has a seating area to promote outdoor activities. The facility has a library and a sensory area to stimulate neurological skills.
Food Service: Sufficient food supplies were observed of perishables for at least 2 days and non-perishables for at least 7 days. Commercial food supplies were observed. The list of residents with special diets was posted in the kitchen. Pest was not observed. Staff were observed using hygiene and contamination prevention methods. (CONTINUED ON LIC 809C)

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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
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: 04/10/2025

NARRATIVE

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Incidental Medical and Dental: Wellness room is used to stored in house medications, refrigerated medications, and surplus medications. Medication carts are located in the studio dining room and were observed locked. Medications are label and in their original containers. LPAs reviewed medications for 5 residents.
Resident Records/Incident Reports: Residents records were available for review. LPA reviewed a total of 5 resident files which contained medical assessment, TB clearance, admission agreement, an appraisal, a needs and care plan.
Disaster Preparedness: Emergency Disaster plan (LIC 610E 3/19), it has been reviewed within a year. Last Emergency drill was conducted on 3/5/25, quarterly emergency drills are being conducted. Emergency evacuation chairs were observed at the top of each exit door.
Residents with Special Health Needs: Postural support/bed rails were observed and physician's request were observed in residents files who are under hospice. Facility is following dementia regulations. Facility has a fenced pond/water feature in the courtyard. Medical assessments for residents with dementia were observed within the last 12 months. All egress exit doors were tested and are in working condition. Facility keeps hospice plan on file.

No deficiencies were noted during this visit.

Exit interview was conducted with Administrator and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC809 (FAS) - (06/04)

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