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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607820
Report Date: 03/23/2021
Date Signed: 03/23/2021 01:06:16 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:
03/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Annabelle Argenal - AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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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.

*It should be noted this is a second report as an updated copy of the report created on 3/18/21 regarding the incident report, as the first report was not uploaded to the department's system due to technical difficulties/errors.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
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: 03/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2021
Section Cited

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87468.1 Personal Rights of Residents in all Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requiremetn is not met as evidence by:
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Based on observation and interviews, facility did not ensure staff treated resident with dignity in their personal relationship between S1 and R1 which poses an immediate health, safety, or personal rights risk to personal care.
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Type A
03/19/2021
Section Cited

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87468.1 Personal Rights of Residents in all Facilties: (a) Residents in all residential care... shall... (3)... be free from punishment, humilation, intimidation, abuse, or other actions of a punitive nature,...

This requirement is not met as evidence by:
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Based on observation and interviews, facility did not avoid staff from humiling, intimidating, abuse, or other punitive actions towards R1, which poses an immediate health, safety, or personal rights 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: 03/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2021
LIC809 (FAS) - (06/04)
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