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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607820
Report Date: 10/19/2021
Date Signed: 10/19/2021 10:02:32 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: 62DATE:
10/19/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Gina Lopez - Business Office ManagerTIME COMPLETED:
10:15 AM
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Licensing Program Analyst(s) Mary Flores and Jewel Baptiste conducted a plan of correction (POC) visit at the facility regarding deficiencies given on 10/7/21.

On 10/7/21 LPA Flores conducted a complaint investigation and case management and gave 2 type A deficiencies. Today's visit LPA observed the following:

87705 Care of Persons with Dementia - Main entrance to the facility does not have an auditory device or staff alert feature to ensure that dementia residents do not leave the facility unassisted. During today's visit LPAs observed that main entrance door to the facility continues to not have an auditory device or staff alert feature. However, the facility provided a copy of a proposal and contract via email on 10/8/21 and LPA verified with contracted agency, who stated the magnetic lock will be place by the end of the week as the parts haven't arrived, contractor emailed LPA invoice for parts order on 10/8/21. Deficiency cleared on 10/19/21.

87706 Advertising Dementia Special Care, Programming, and Environments: Facility had 7 residents with a dementia diagnose on the assisted living area. During today's visit LPAs were not provided an updated plan of operation.*Therefore civil penalties have been assess for failure to correct at $1100.*


Exit interview was conducted with Gina Lopez Business Office Manager and a copy of this report and LIC 421 were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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