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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607820
Report Date: 10/07/2021
Date Signed: 10/07/2021 10:54:59 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: 64DATE:
10/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Gina Lopez - Business Office ManagerTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit during a complaint investigation. LPA Flores met with Gina Lopez and explained the reason for the visit.

LPA Flores requested staff and resident roster with a list of dementia resident. LPA was provided a roster in which was noted current census for dementia unit is 18 residents. In the assisted living roster 7 residents were noted as dementia residents. LPA Flores reviewed and requested copies of physician's report for resident #1(R1), #2(R2), #3(R3), #4(R4), #5(R5), #6(R6), #7(R7).


Based on Title 22 Regulations Deficiencies will be noted on LIC 809D.

Exit interview was conducted with Brianna Goodlet - Assistant Administrator r and a copy of this report, LIC 809D, and appeal rights 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
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: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited

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87705 Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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Based on documents reviewed and observation licensee did not ensure facility has an auditory device or other staff alert feature to monitor main entrance 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
LIC809 (FAS) - (06/04)
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