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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607820
Report Date: 10/07/2021
Date Signed: 10/07/2021 10:52:09 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/25/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20210625104126
FACILITY NAME:REGENCY PARK ASTORIAFACILITY NUMBER:
197607820
ADMINISTRATOR:ANNABELLE ARGENALFACILITY TYPE:
740
ADDRESS:925 EAST VILLA STREETTELEPHONE:
(626) 796-4303
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:220CENSUS: 64DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Gina Lopez - Business Office Manager TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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9
Facility does not provide a safe environment for resident.
INVESTIGATION FINDINGS:
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13
This report supersedes report dated 6/29/21 to provided corrected substantiated finding for allegation; facility does not provide a safe environment for resident.

On 6/29/21 Licensing Program Analyst(s) (LPA)Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Marisela Soria, Wellness coordinator and explained the reason of the visit. Assistant administrator Brianna Goodlet arrived an hour later.

The investigation consisted of the following: On 6/29/21 LPA Flores conducted a tour of residents' rooms randomly chosen, room #134,151,200, 203,244, interviewed residents #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7) and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5),#6(S6), interview resident #7(R7) over the phone and requested copies of R1,R2,R3,R4,R5,R6 identification and emergency information, physician's report, appraisal/needs and service plan, and medication sheet.

(CONTINUED LIC (9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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 5
Control Number 28-AS-20210625104126
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASTORIA
FACILITY NUMBER: 197607820
VISIT DATE: 10/07/2021
NARRATIVE
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Regarding allegation: Facility does not provide a safe environment for resident. It is alleged resident has dementia and is residing in the general housing section of the facility instead of the memory care unit. During interviews with residents, 4 out of 7 residents interview stated not to have heard or observed residents in hallways disturbing or banging on doors, and residents feel good about living at the facility. 2 out of 7 residents stated facility staff responds to residents needs. 2 out 7 residents were unable to be interview due to cognitive skills. During interviews with staff, 2 out of 6 staff stated there is a resident in independent living who recently has shown a change of condition in the last few weeks who is currently being monitored by staff and physician and has a follow up appointment scheduled, however behavior is not harmful towards other residents or self. 3 out of 6 staff interview stated to not be aware or heard of residents being disruptive. Wellness coordinator stated any resident leaving the facility must sign out before leaving facility with receptionist on lobby. Documents reviewed revealed 3 residents have a primary diagnosis of dementia of which 2 of the 3 residents reside in the memory care unit and 1 in the assisted living area. Assisting Living, facility's main entrance does not have an auditory device or staff alert feature to monitor the main entrance.

Based on LPA's interviews, observation, and document review conducted the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED.


Exit interview was conducted with Assistant Administrator Brianna Goodlet and a copy of this report, LIC 9099D, and appeal rights were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/25/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20210625104126

FACILITY NAME:REGENCY PARK ASTORIAFACILITY NUMBER:
197607820
ADMINISTRATOR:ANNABELLE ARGENALFACILITY TYPE:
740
ADDRESS:925 EAST VILLA STREETTELEPHONE:
(626) 796-4303
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:220CENSUS: 64DATE:
10/07/2021
UNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Gina Lopez - Business Office Manager TIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff does not adequately supervise resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report supersedes report dated 6/29/21 to provided corrected substantiated finding for allegation; facility does not provide a safe environment for resident.

On 6/29/21 Licensing Program Analyst(s) (LPA)Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Marisela Soria, Wellness coordinator and explained the reason of the visit. Assistant administrator Brianna Goodlet arrived an hour later.

The investigation consisted of the following: On 6/29/21 LPA Flores conducted a tour of residents' rooms randomly chosen, room #134,151,200, 203,244, interviewed residents #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7) and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5),#6(S6), interview resident #7(R7) over the phone and requested copies of R1,R2,R3,R4,R5,R6 identification and emergency information, physician's report, appraisal/needs and service plan, and medication sheet.

(CONTINUED LIC (9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20210625104126
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASTORIA
FACILITY NUMBER: 197607820
VISIT DATE: 10/07/2021
NARRATIVE
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The investigation revealed the following: Regarding allegation; facility staff does not adequately supervise residents. It is alleged resident wanders the facility banging on residents doors. During interviews with residents, 4 out of 7 residents interview stated not to have heard or observed residents in hallways disturbing or banging on doors. 2 out 7 residents were unable to be interview due to cognitive skills. 1 out of 7 residents stated there is a resident who has knocked at her door twice looking for spouse. During interviews with staff, 2 out of 6 staff stated there is a resident in independent living who recently has shown a change in condition in the last few weeks, who is currently being monitored by staff and physician and has a follow up appointment scheduled on 7/1/21. 3 out of 6 staff interview stated to not be aware or heard of residents being disruptive in the independent living side. 1 out of 6 staff stated a resident knocked at other resident's door once looking for spouse but there was no disruptive or dangerous behavior observed. Assistant Administrator stated there is a total of 4 caregivers and 2 med tech during day shift. Documents reviewed revealed residents have a current physician report conducted within the last year and a current or updated appraisal/needs an service plan reviewed within the last 8 months and facility is currently monitoring residents change in condition or following up with needs.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove
the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted with Assistant Administrator Brianna Goodlet and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210625104126
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASTORIA
FACILITY NUMBER: 197607820
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited
CCR
87706(a)(2)(H)
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87706 Advertising Dementia Special Care, Programming, and Environments: (a) In addition...shall meet...: (2) ...shall include in the plan of operation...: (H)...environmental factors that ensure a safe, secure, familiar and consistent environment for residents with dementia.
This requirement is not met as evidence by:
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Licensee will update plan of operation to include providing a safe environment for residents with dementia diagnose residing in assisted living. Licensee will submit plan of operation by 10/8/21.
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Based on interviews, observation, and document review licensee did not ensure resident #4 resides in the dementia unit which poses an immediate Health, Safety, or Personal Rights risk for 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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5