198602039-9-7-2024-11-AS-AINZ-D8VTJA-20240907144602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602039
Report Date: 09/07/2024
Date Signed: 09/07/2024 02:46:10 PM

Document Has Been Signed on 09/07/2024 02:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	REGENT VILLA RETIREMENT HOME		FACILITY NUMBER:	198602039
ADMINISTRATOR:	GORDON, JENNI		FACILITY TYPE:	740
ADDRESS:	201 W WARDLOW RD		TELEPHONE:	(562) 595-6529
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	188	CENSUS: 130	DATE:	09/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Karina Solomon/Assistant Administrator		TIME COMPLETED:	02:45 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 9/7/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Karina Salomon /Assistant Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (188) elderly adults ages 60 and above, of which (40) can be non-ambulatory. The facility has an approved hospice waiver for (3).

The facility is a two-story commercial building that consist of (94) resident bedrooms, (94) resident bathrooms, eight (8) common bathrooms, dining room, commercial kitchen, staff area, office area, commercial washer and dryer room/ storage area, Movie room, activity room, backyard with umbrella with table and chairs.

LPA Iniguez and the Assistant Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (6) bedrooms and (6) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 109.5°F to 110.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REGENT VILLA RETIREMENT HOME	FACILITY NUMBER: 198602039
	VISIT DATE: 09/07/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 7/31/24.

A review of (6) residents' service files and (6) staff personnel files was maintained in order. LPA reviewed (6) Medication Administration Records (MARs) discrepancies found.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current.

Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-MedTech’s not documenting medication given/refusal on MARs for R#2 and R#5.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Karina Salomon / Assistant Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/07/2024 02:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REGENT VILLA RETIREMENT HOME	FACILITY NUMBER: 198602039
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not documenting properly the medication administration/refusal for R#2 and R#5 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2024
	Plan of Correction
1 2 3 4	Licensee will ensure that medication is given according to the physician's direction. As part of Plan of Correction (POC), licensee will re-train medtechs and persons who dispense medication regarding the importance of documenting properly on the resident's Medication Administration Records (MARs) at all times. As proof of correction, licensee will sent copies of in-service training to LPA via email before POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3