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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602039
Report Date: 02/11/2022
Date Signed: 03/01/2022 01:02:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2022 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220125102506
FACILITY NAME:REGENT VILLA RETIREMENT HOMEFACILITY NUMBER:
198602039
ADMINISTRATOR:GORDON, JENNIFACILITY TYPE:
740
ADDRESS:201 W WARDLOW RDTELEPHONE:
(562) 595-6529
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:188CENSUS: 147DATE:
02/11/2022
UNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Kathy ZepedaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Illegal Eviction
Resident personal items missing
INVESTIGATION FINDINGS:
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On 2/11/2022 at 9:37 a.m, Licensing Program Analyst (LPA)/ Susan Campos, initiated a subsequent complaint investigation visit for the allegations listed above. LPA was allowed entry into the facility by Kathy . LPA explained to Ms. Gordon the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (6) staff members and (4) residents on 2/3/22. In addition, on 2/3/22, LPA and Ms. Gordon conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. LPA also reviewed the following documents provided by Regent Villa Retirement Center Administrator Jenni Gordon: LIC 500-Staff roster, Client roster, Staff schedule, Incident Reports from January 2022 to present, Internal staff incident reports from January 2022 to present, House Rules, Resident Personal Item Intake procedures, R1 Admission Agreement, R1 Personal Item List, R1 case notes, R1 physician report, R1 service care plan and R1 medical documents.

Report continued on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2022 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220125102506

FACILITY NAME:REGENT VILLA RETIREMENT HOMEFACILITY NUMBER:
198602039
ADMINISTRATOR:GORDON, JENNIFACILITY TYPE:
740
ADDRESS:201 W WARDLOW RDTELEPHONE:
(562) 595-6529
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:188CENSUS: 147DATE:
02/11/2022
UNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Kathy ZepedaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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2
3
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9
Facility did not notify responsible party of resident's change in condition
Facility did not release resident's belongings in a timely manner
Staff push resident
Staff transfer resident for medical treatment without permission from resident
Resident threatened by another resident.
INVESTIGATION FINDINGS:
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On 2/11/2022 at 9:37 a.m, Licensing Program Analyst (LPA)/ Susan Campos, initiated a subsequent complaint investigation visit for the allegations listed above. LPA was allowed entry into the facility by Kathy . LPA explained to Ms. Gordon the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (6) staff members and (4) residents on 2/3/22. In addition, on 2/3/22, LPA and Ms. Gordon conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. LPA also reviewed the following documents provided by Regent Villa Retirement Center Administrator Jenni Gordon: LIC 500-Staff roster, Client roster, Staff schedule, Incident Reports from January 2022 to present, Internal staff incident reports from January 2022 to present, House Rules, Resident Personal Item Intake procedures, R1 Admission Agreement, R1 Personal Item List, R1 case notes, R1 physician report, R1 service care plan and R1 medical documents.

Report continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20220125102506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: REGENT VILLA RETIREMENT HOME
FACILITY NUMBER: 198602039
VISIT DATE: 02/11/2022
NARRATIVE
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that did not know where was going, or that did not want to leave the facility. The medical staff also informed R1 of the medical treatment, and R1 did not inform the medical staff that did not know where was going or that did not want medical treatment.

Based on information gathered, LPA did not find sufficient evidence to support allegation "Staff did not transfer resident for medical treatment without permission from resident ”

Allegation: Resident threatened by another resident

The investigation revealed, per LPA interviews, with (6) staff members, and (14) residents from the Regent Villa Retirement Home, that residents do not threaten other residents in the facility. S1 informed the LPA that has never received a report, from staff, resident or family member that a resident threatened another resident in the facility. S1 informed the LPA that all residents in the facility get along. The LPA interviewed 6 staff members, and 6 of 6 staff members informed the LPA that they have never heard a resident threaten another resident and also 6 of 6 staff members informed the LPA that staff members, residents and family members have not informed them that a resident threatened another resident in the facility. The LPA interviewed 14 residents and 13 of 14 residents informed the LPA that they have never been threatened by another resident in the facility, and also 13 of 14 residents informed the LPA, that they like and get along with the other residents in the facility.

Based on information gathered, LPA did not find sufficient evidence to support allegation "Resident threatened by another resident ”

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Kathy Zepeda, Activity Director, and a copy of a LIC 9099 report was provided.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20220125102506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: REGENT VILLA RETIREMENT HOME
FACILITY NUMBER: 198602039
VISIT DATE: 02/11/2022
NARRATIVE
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Investigation Revealed

Allegation: Facility did not notify responsible party of resident's change in condition

The investigation revealed, per LPA interviews, with (6) staff members, and (14) residents from the Regent Villa Retirement Home, that facility resident family members/ responsible party are notified of any changes to a resident’s health condition. S1, informed the LPA that all changes to a resident’s health are documented in their case file. S1 also stated that S2 makes sure that family members are notified and also arranges medical appointments. In addition, S1 and S2 inform family of resident incidents that occur in the facility. There has never been an issue with a resident’s family member not being notified of changes to a resident’s condition. S1 informed the LPA that R1’s POA was notified of change of medical condition as a result of event on 2/6/22. S1 stated that contacted R1’s POA, and informed of R1’s medical treatment. R1’s POA did not inform that there were any concerns with R1’s medical treatment. In addition, the LPA interviewed 6 staff persons and 6 of 6 staff persons, informed the LPA that the facility, always documents, and informs the resident’s family or responsible part of health care condition, or treatment. The LPA also interviewed 14 residents, and 13 of 14 residents informed the LPA that the facility assists them with medical concerns, and inform their family of any medical updates.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Facility did not notify responsible party of resident's change in condition ”

Allegation: Facility did not release resident's belongings in a timely manner

The investigation revealed, per LPA interviews, with (6) staff members, and (14) residents from the Regent Villa Retirement Home, that staff release resident’s belongings in a timely manner. S1 informed R1’s POA, R1’s items were packaged and once the new facility contacted S1, to arrange, the items transport to the new facility. R1’s personal belongings were packaged in several large bags and boxes, and required a van/ truck for transport. The new facility informed S1, that they did not have a vehicle, and if S1 would be able to transport R1’s items to the new facility. S1 informed the LPA, that they also did not have a truck or staff to transport R1’s items, so S1 hired a driver, to transport R1’s items to the new facility. The driver transported R1’s items to the new facility, one week after new facility’s request. S1 informed the LPA, that they are not responsible for the transport of resident’s personal belonging to their new facility, and R1’s POA requested S1 to transport R1’s personal items.

Report continued on LIC 9099C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20220125102506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: REGENT VILLA RETIREMENT HOME
FACILITY NUMBER: 198602039
VISIT DATE: 02/11/2022
NARRATIVE
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Based on information gathered, LPA did not find sufficient evidence to support allegation " Facility did release resident’s belongings in a timely manner ”

Allegation: Staff push resident

The investigation revealed, per LPA interviews, with (6) staff members, and (14) residents from the Regent Villa Retirement Home, that the staff at the Regent Villa Retirement Home do not push residents. S1 informed the LPA, that has never received a report from staff, residents or family members, that a staff person pushed a facility resident and also has never witnessed a staff person push a resident. Furthermore, S1 stated that a staff person pushing a resident would never be allowed, and that there would be disciplinary actions for the staff person. Also, S1 stated that the staff at the Regent Villa Retirement Home are trained, on how to interact with residents, and also work as a team, if a staff person needs assistance, another staff person comes to assist. The LPA interviewed 6 staff members, and 6 of 6 staff members informed the LPA, that they have never witnessed a staff person push a resident, and also have never received a report from a staff member, resident or family member that a staff person pushed a resident. In addition, the LPA interviewed 14 residents from the Regent Villa Retirement Home, and was informed by 13 of 14 residents, that they have never been pushed by a facility staff person. In addition, 13 of 14 residents, informed the LPA that they like the staff at the facility, and that they feel comfortable being around the facility staff.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff push resident”

Allegation: Staff transfer resident for medical treatment without permission from resident

The investigation revealed, per LPA interviews, with (6) staff members, and (14) residents from the Regent Villa Retirement Home, that staff do not transfer residents for medical treatment without the permission from the resident. S1 informed the LPA that the residents at the facility are informed of any and all medical treatments they receive. Furthermore, the facility does not conduct or is involved with medical treatments. All resident medical treatments are conducted by medical staff, and resident family members are involved with the resident’s medical care. On 2/6/22, medical staff informed S1, and S2, that R1 had agreed to medical treatment, and that medical transport will pick up R1 at the facility. S1 stated that contacted R1’s POA, and informed POA that R1 would be receiving medical treatment per R1’s consent. On 2/7/22, S1, S2 and S3 escorted and witnessed R1 board the medical transportation vehicle, and R1 never informed S1, S2 and S3,

Report continued on LIC 9099C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20220125102506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: REGENT VILLA RETIREMENT HOME
FACILITY NUMBER: 198602039
VISIT DATE: 02/11/2022
NARRATIVE
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On 2/3/22, at 3pm, the LPA was informed by S1, that C1’s missing items are not in the facility, and that Regent Villa Retirement Home will reimburse R1 for the cost of the lost items.

Based on information gathered, LPA did find sufficient evidence to support allegation "Resident personal items missing ”

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Kathy Zepeda, Activity Director and a hard copy of a LIC 9099 and LIC 9099D was provided.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 11-AS-20220125102506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: REGENT VILLA RETIREMENT HOME
FACILITY NUMBER: 198602039
VISIT DATE: 02/11/2022
NARRATIVE
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Investigation Revealed

Allegation: Illegal Eviction

The investigation revealed, per LPA interviews, with (6) staff members, and (14) residents from the Regent Villa Retirement Home, that a resident was illegally evicted from the facility. S1 informed the LPA, that on 2/6/22, R1 physically attacked S4, while S4 was distributing coffee in the hallway. S4 refused to pour coffee into R1’s mug. At this time, the facility residents were in COVID quarantine, per Department of Public Health orders, and as a result, all residents were served meals and drinks in their room. As a result of R1’s violent physical behavior towards S4, S1 informed R1’s POA of R1’s incident with S4, and also informed, that R1 could no longer live in the facility. R1 left the facility on 2/7/22, for medical treatment, and did not return to the Regent Villa Retirement Home facility, and R1 is now living in another facility.

On 2/4/22 at 2pm, LPA was informed by S1, that contacted R1’s POA, and informed R1’s POA, that R1 could not live in the facility, as a result of 2/6/22 incident with S4. S1 did not give R1’s POA an eviction notice.

Based on information gathered, LPA did find sufficient evidence to support allegation " Illegal Eviction ”

Allegation: Resident personal items missing

The investigation revealed, per LPA interviews, with (6) staff members, and (14) residents from the Regent Villa Retirement Home, that resident’s personal items are missing. S1 informed LPA that R1 does not live in the facility. S1 also stated that S1 made arrangements for R1’s items to be delivered to R1’s new residential location. S1 stated that if there are items missing from the deliver, S1 is not aware, because all items in R1’s room were packed, and safely stored. S1 reviewed R1’s missing item list, and informed the LPA that the items are not in the facility. Furthermore, S1 informed the LPA that Regent Villa Resident Home will reimburse R1 for missing items from room. The LPA interviewed (6) staff members and 6 of 6 staff members informed the LPA that they are not aware of a resident’s missing items from their room. In addition, the LPA interviewed 14 residents, and 13 of 14 residents interviewed informed the LPA that they are not missing items from their resident room.

Report continued on LIC 9099C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20220125102506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: REGENT VILLA RETIREMENT HOME
FACILITY NUMBER: 198602039
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
87224(a)
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87224 Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)

This requirement is not met as evidenced by:
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Administrator will review 87224 Eviction Procedures, and provide LPA per fax statement that administrator understands eviction procedure regulation, and also that will contact LPA regarding future resident evictions.
Due Date: 3/4/22
LPA Fax No.: (323)981-1781
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Based on interviews, and record review,
On 2/3/22, S1 informed LPA, that informed R1's POA that R1 could not live in the facility, because of physical altercation with S4, which posed a potential health risk to residents in care.

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Type B
03/18/2022
Section Cited
CCR
87218(a)(2)
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87218Theft and Loss(a)The licensee shall ensure an adequate theft and loss program...(2)A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value...

This requirement is not met as evidenced by:
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Administrator will fax to LPA invoice/ payment for reimbursement of R1's lost personal items.

Due Date: 3/18/22
LPA Fax No.: (323)981-1781
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Based on interviews, and record review, the licensee failed to ensure the safety of C1's personal items. On 2/3/22, S1 informed the LPA that R1's personal items were not in room, and that S1 would reimburse R1 for lost items, which posed a potential health risk to residents 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.
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Susan Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 8