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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607820
Report Date: 03/10/2021
Date Signed: 03/10/2021 04:52:54 PM

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: 54DATE:
03/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Brianna Goodlet - Assistant AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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LPA Flores conducted a Case Management visit as a follow up to death report submitted to the department on 3/8/21. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Brianna Goodlet, facility assistant administrator.

On 3/8/21 LPA Flores received a death report for R#1 submitted to the department by the facility's assistant administrator via fax. Death report stated R#1 pass away on 1/9/21, cause of death COVID related, R#1 passed away at Huntington Hospital. R#1 was hospitalize since 12/15/20.

Per Title 22 California Regulation Code Chapter 8 Division 6; 87211 Reporting Requirements; Licensed facility is to report any death within 7 days of the occurrence to the department.

Deficiencies cited and noted on 809D.

Exit interview with Brianna Goodlet, a copy of this report was email for signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2021
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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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: 03/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2021
Section Cited

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87211 Reporting Requirements; (a) Each licensee shall furnish...: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence... (A) Death of any resident from any cause regardless of where the death occurred...
This requeriments is not met as evidence by:
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Based on documents reviewed, facility failed to report R#1 within the seven days of occurance which poses a potential Health, Safety, and Personal Risk to 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: 03/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2021
LIC809 (FAS) - (06/04)
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