191200037-5-9-2024-28-AS-MGFS-D54TTA-20240509150024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191200037
Report Date: 05/09/2024
Date Signed: 05/09/2024 03:00:41 PM

Document Has Been Signed on 05/09/2024 03:00 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:	ANABELLE ARGENAL		FACILITY TYPE:	740
ADDRESS:	255 SOUTH OAK KNOLL		TELEPHONE:	(626) 578-1551
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY:	206	CENSUS: 82	DATE:	05/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:36 AM
MET WITH:	Jacqueline Hernandez - Business Services Director		TIME COMPLETED:	03:15 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 (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Jacqueline Hernandez 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, and patio in the second floor. LPA toured the facility with Jacqueline Hernandez and observed the following: First Floor: Lobby and family room are clean in good repair, fireplace is covered. Dining room has an uncovered rectangle shape hole of about 4ft x 3ft. Per maintenance a leak was noticed this morning and the hole was cut to prevent leaking. Kitchen was observed clean, sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. List of special diets posted. Egress exit doors were checked down stairs and in working condition. Passageway from the exit door of the laundry was tested. LPA observed a food tray cart, trash cans, and laundry moving cart blocking the exit at the end of the passageway by the parking lot. Local Ombudsman and PUB 745 are posted in the hallway to the parlor. Parlor is clean and in good repair. Medication room and carts located in the studio dining room were observed locked. Emergency food supplies were observed in a closet by the kitchen. Common shower across from the elevator does not have skid strips/mats. Second Floor: Library's fireplace is covered, TV room, conference room were observed clean and in good repair. Three (3) egress exit doors were tested and are in working condition. Emergency evacuation chairs were observed at the top of each exit door. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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 05/09/2024 03:00 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
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: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 4 out of 9 resident's bathrooms water temperature was tested as follow; room #246 tested at 121.1, room #223 tested at 121.2, room #231 tested at 122.1, room #104 tested at 120.2 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	Admininstrator will adjust water temperature and will certify in writing that will ensure water temperature is within the required 105-120 degrees F. Administrator will submit this in writing to the department by POC due date 5/10/24 and will keep a daily log for the water temperature in the above rooms for 7 days and will submit a copy to the department.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/09/2024 03:00 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
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: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in common shower does not have a skid mat/strip which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/16/2024
	Plan of Correction
1 2 3 4	Administrator will ensure a skid mat/strip is provided in the common shower to ensure the safety of the residents and will submit a picture to the department by POC due date 5/16/24.

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in passageway exit from the egress exit door of laundry towards the kitchen ending at the parking lot was observed blocked with laundry cart, food tray cart, and trash cans which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/16/2024
	Plan of Correction
1 2 3 4	Administrator will ensure passaways are clear of obstructions and will provide in-service training to staff regarding Emergency Procedures, Safety, and Evacuation will submit a copy of the log with duration of in-service, signing log, topic discuss to the department by POC due date 5/16/24.

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: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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: 05/09/2024

NARRATIVE

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A total of 9 randomly picked resident bedrooms were observed and each have the required furniture, bedding supplies, and sufficient lighting. Each room has a private bathroom, LPA tested water temperature in each and tested between 110.1 - 122.1 degrees F., which is not within the required 105-120 degrees F.

Facility has a fire sprinkle system throughout the building. Fire extinguishers were observed and last checked on 7/10/23. Courtyard is enclosed and has sufficient seating shaded area. Upstairs patio is fenced and has a sufficient seating area. Water feature pond is fence around. This facility serves as a dementia building,

LPA reviewed medication with Med-Tech staff for 9 residents. LPA reviewed files for 8 residents.

During today's visit LPA completed the following domains:
Physical Plant and Environment Safety
Resident Right - Information
Food Services
Incidental Medical and Dental
Resident Record - Incident Reports
Planned Activities

LPA will return at a later time to conclude the annual visit and finish additional CARE tool inspection domains.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Annabelle Argenal and a copy of this report, LIC 809D, 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: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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