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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607820
Report Date: 03/18/2021
Date Signed: 03/23/2021 09:22:46 AM

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:
03/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Annabelle Argenal - Administrator TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Mary Flores conducted a case management visit as a follow up for unusual incident report submitted to the department on 3/16/21. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Annabelle, the facility administrator.

Unusual incident report stated that it was reported that R1 complaint that S1 stomp on his feet on 3/9/21. Facility conducted an in-house investigation and their investigation revealed S1 had showed previously inappropriate behaviors. Facility conducted an in-service training for all staff on 3/11/21. Facility removed S1 from schedule on 3/9/21 and terminated S1 on 3/18/21.

Per Title 22 Regulations, Division 6, Chapter 8. Personal Rights of Residents in All Facilities; Personal Rights of residents are not to be violated at any time.

Deficiencies were found during this visit and noted on 809D.

A copy of this report was email to Annabelle Argenal for signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2021
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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