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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607820
Report Date: 09/12/2022
Date Signed: 09/12/2022 05:25:13 PM


Document Has Been Signed on 09/12/2022 05:25 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 ASTORIAFACILITY NUMBER:
197607820
ADMINISTRATOR:ANNABELLE ARGENALFACILITY TYPE:
740
ADDRESS:925 EAST VILLA STREETTELEPHONE:
(626) 796-4303
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:220CENSUS: 83DATE:
09/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Brianna Goodlet - Assistant Administrator TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores, and Luis Mora conducted a case management visit - deficiencies during a pre-licensing visit - change of ownership visit at the facility on 9/12/22.

The following was observed during the facility's tour:

Resident's room #145 was observed to have outlet cover plate hanging from lamp cord and room #103 was observed to have a hole in the wall of about 2 inches by 4 inches above the resident's clock. Water temperature was measure in each resident's bathroom and in rooms #160, 159, 156, 153, 152, 150, 149, 145, 141, 139 water tested between 101.6 - 104.3 degrees F., which is not within the required 105 - 120 degrees F. Facility has a sprinkle fire system and carbon monoxide detectors were observed in each room. Skid strips/mats were missing in room #141 and #153. All common areas were observed in good repair, with sufficient furniture. Medication was observed in room #256. Cleaning supplies were observed in room #155.

Deficiencies were given and noted on LIC 809D per Title 22 Regulations Division 6 Chapter 8.

Exit interview was conducted with Brianna Goodlet Assistant Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 09/12/2022 05:25 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 ASTORIA
FACILITY NUMBER: 197607820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2022
Section Cited

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87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents...:(2) Over-the-counter medication, nutritional supplements or vitamins, ... cleaning supplies and disinfectants.


This requirement is not met as evidence by:
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Based on observation licensee did not ensure resident #1 in room #155 did not keep cleaning supplies which poses an immediate health, safety, or personal right risk to persons in care.
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Type A
09/13/2022
Section Cited

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Incidental Medical and Dental Care: (h) The following... shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of ... stored medication.
This requirement is not met as evidence by;
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Based on observation licensee did not ensure resident # 2 in room #256 did not store medication which poses an immediate health, safety, or personal rights risk 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: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/12/2022 05:25 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 ASTORIA
FACILITY NUMBER: 197607820

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2022
Section Cited

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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidence by:
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Based on observation licensee did not ensure outlet cover plate was not on the electrical outlet in room #145 and hole in the wall in room #103 was fixed which poses a potential health, safety, or personal rights risk to the persons in care.
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Type B
09/19/2022
Section Cited

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87303 Maintenance and Operation: (e) Water supplies... shall be maintained...: (2) Faucets used by residents for personal care...shall deliver hot water... shall be maintained to automatically regulate... to attain a temperature of not less than 105 degree F... and not more than120 degreeF... This requirement is not met as evidence by:
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Based on observation licensee did not ensure water temperature was maintain between 105 - 120 degrees F., which poses a potential health, safety, personal rights risk 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: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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