191200037-6-2-2023-28-AS-TVAO-CT7NZL-20230627105431

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191200037
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:32:04 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230526091805

FACILITY NAME:	REGENCY PARK OAK KNOLL		FACILITY NUMBER:	191200037
ADMINISTRATOR:	ANABELLE ARGENAL		FACILITY TYPE:	740
ADDRESS:	255 SOUTH OAK KNOLL		TELEPHONE:	(626) 578-1551
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY:	206	CENSUS: 79	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	08:02 AM
MET WITH:	Jacqueline Hernandez - Business Manager		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not follow reporting requirements in a timely manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Jacqueline Hernandez Business Manager and explained the reason for the visit. Administrator arrived 45 minutes later.

The investigation consisted of the following: LPA Flores requested a copy of staff/resident rosters. LPA interviewed administrator and requested copies of staff physician's notes for staff #1, #2, and resident #1.

The investigation revealed the following: Regarding allegation: Facility staff did not follow reporting requirements in a timely manner. It is alleged facility failed to report scabies breakout to proper agencies. Documents review revealed, on 5/11/23 staff #1(S1) provided a physician's note with a diagnosis of scabies and was placed on leave. On 5/22/23 staff #2 provided a physician's note that rule out scabies. On 5/25/23 facility's administrator contacted Pasadena Department of Public Health (PDPH) via phone call and reported 2 scabies cases confirmed on 5/11/23 and 5/23/23 for 2 staff. (CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20230526091805

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/02/2023

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
26
27
28
29
30
31
32

On 6/2/23 administrator reported resident #1(R1) was treated for scabies per physician's recommendation on discharge documents dated 5/23/23. Per PDPH a typical scabies case should be reported upon having 2 confirmed cases immediately via telephone and per Title 22 Regulations any incident that threatens the health and safety of the residents must be reported within 7 days to the department via an unusual incident report. No unusual incident reports were received by the department for any of the cases described above. Facility failed to report via an unusual report within 7 days of the occurrence.

Based on documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.

Exit interview was conducted with Annabelle Argenal Administrator and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230526091805

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/06/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements: (a) Each licensee shall furnish... (1) A written report shall be submitted...within seven days of the occurrence of (D) Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator will submit unusual incident report for S1 and R1 to the department for scabies case/treatment by 6/6/23 and will ensure to report timely to PDPH.
	8 9 10 11 12 13 14	Based on documents reviewed licensee did not ensure to report scabies cases to the CLLD and PDPH in a timely manner which poses a potential health, safety, or personal right risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3