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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191200037
Report Date: 11/18/2022
Date Signed: 11/18/2022 03:38:24 PM


Document Has Been Signed on 11/18/2022 03:38 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
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: DATE:
11/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Jeanine Hernandez - Assistant Administrator TIME 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 an incident report submitted to the department on 8/12/22. LPA Flores met with Jeanine Hernandez Assistant Administrator and explained the reason for the visit.

On 8/12/22 LPA Flores received an incident report (SIR) regarding Resident #1(R1) found by Pasadena Police Department 3 blocks away from the facility. On 8/26/22 LPA Flores requested facility to submit to the department physician's report, admission agreement, needs and service care plan, medication sheet, and face sheet. On 11/16/22 LPA Flores contacted administrator to request the documents listed to be submitted to the department.
On 11/18/22 LPA Flores reviewed the documents faxed to the department. Per physician's report reviewed R1 is not allowed to leave the facility unattended and notes wandering behavior. R1 was admitted to the facility on 8/9/22. R1's physician's report notes R1's secondary diagnose is Alzheimer's and has mild cognitive impairment. Preplacement assessment notes R1 wandering behaviors. On 11/18/22 LPA interviewed assistant administrator, staff #2(S2), R1 and representative of R1. LPA observed 3 exit points, main entrance has a lock door and a concierge is in the lobby to allow entry and exit. Exit door near the laundry exits to passage way to egress exit Laundry door gate/west exit which has the 15 seconds hold and the sound device has been quite due to neighbors concerns. The egress system notifies the front desk and front desk staff notified on radio. North gate has egress system and alarm was set off once assistant administrator open the gate. North Gate exits to the street to the right of the main entrance. North Gate was used by R1 to exit facility. Interview with Assistant Administrator revealed R1 left the facility before 4:00pm and was brought back by police department at 4:30pm. Facility provided a copy of S2 Performance Improvement Notice dated 8/15/22. Facility is currently providing hourly checks for R1.
Deficiencies have been noted on LIC 809D per Title 22 Regulations.
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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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Document Has Been Signed on 11/18/2022 03:38 PM - It Cannot Be Edited

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: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2022
Section Cited

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a) ... Section 87468.1, Personal Rights of Residents...(4) To care, supervision,... meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidence by:
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Based on documents review facility did not ensure R1 did not leave the facility unattended which is an immediate risk to the health, safety, or personal rights 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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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