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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607820
Report Date: 12/09/2021
Date Signed: 12/09/2021 01:35:48 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: 67DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:33 AM
MET WITH:Gina Lopez Business Administrator
Brianna Goodlet - Assistant Administrator
TIME COMPLETED:
08:34 AM
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Licensing Program Analyst(s) (LPA) Mary Flores and Jewel Baptiste conducted an unannounced annual visit with focus on the infection control domain, food, and medication review. LPAs met with Gina Lopez and explained the reason for the visit. Assistant Administrator Brianna Goodlet arrived 15 minutes later.

Facility is licensed to serve 220 residents of which 116 may be non-ambulatory and 104 may be bedridden and may retain up to 15 hospice residents. The facility is currently serving 67 residents and 5 are on hospice. Facility is a two story building with a dementia unit, a commercial kitchen, dinning room, several activities rooms, medication room, and a lobby area. No large bodies of water were observed. Outdoor areas are accessible within the facility for dementia unit and assisted living.
LPAs conducted a tour of the facility with Brianna Goodlet and observed the following:
Commercial kitchen was observed to have sufficient food supplies for at least 2 days worth of perishables, and 7 days of non-perishables. Sharp objects, medication and cleaning supplies are inaccessible to the residents. LPAs observed client rooms #101, #112, #114, #115, #121, #148, #152A, #205, #209, 216, #223. Rooms were clean and in good repair and had all the required furnishings. Bathrooms in rooms observed were observed to be clean and operational with grab bars and skid mats/strips, hot water temperature was measured between 106.9 -114.6 degrees F, which is within Title 22 range of 105-120 degrees F. LPAs observed at least 30 days of PPE supplies and emergency food supplies. Facility red zone was observed having closed lid trash cans and required PPE supplies. LPAs checked medications for resident#1( R1),#2(R2),#3(R3),#4(R4), #5(R5), #6(R6). Fire extinguishers wer observed throughout the facility. Facility has a sprinkler smoke detector system and carbon monoxide detectors were observed thought the facility. COVID 19 recommendations are being followed regarding screening, posting, N95 Fit test has been done, screening residents, staff, and visitor, and testing requirements. Brianna Goodlet Assistant Administrator certificate #6057760740 expiration date: 11/4/22
No deficiencies were provided during this visit.Technical advisories were given for additional signs and social distancing in memory care unit.Exit interview conducted with assistant administrator Brianna Goodlet and a copy of this report and LIC 9102 were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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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