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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602567
Report Date: 05/02/2025
Date Signed: 05/02/2025 09:04:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250501115014
FACILITY NAME:REGENCY PALMS LONG BEACHFACILITY NUMBER:
198602567
ADMINISTRATOR:KENIA SANCHEZ PADILLAFACILITY TYPE:
740
ADDRESS:117 E 8TH STREETTELEPHONE:
(562) 432-9260
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY:91CENSUS: 74DATE:
05/02/2025
UNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Fabiola MarcianoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident had multiple falls in care.
Facility failled to report an incident.
INVESTIGATION FINDINGS:
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On May 2, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced visit to gather information regarding the above allegations. LPA met with Executive Director Fabiola Marciano and explained the purpose of the visit. LPA was granted entry to the facility.

The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 (S1), and resident members #1(R1). List of documents reviewed/obtained Resident Roster (dated 05/01/25), Personnel Report LIC 500 (dated 05/01/25), Provider Communication Form (dated 04/02/25), Unusual Incident Report (dated 05/02/25), and St. Mary’s Medical Records (dated 04/27/25), and other documents pertinent with this complaint.

(Evaluation Report continues LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
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 4
Control Number 11-AS-20250501115014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 05/02/2025
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Resident had multiple falls in care.

The complaint details alleges that Resident #1 (R1) experienced multiple falls while under care. Reports show that (R1), who resides in the memory care unit, has fallen four times in the past two months and has sustained injuries on (R1)'s body. No additional information has been provided regarding this situation.

Resident #1 (R1) was admitted to Regency Palms Senior Living on February 22, 2025, as indicated by their Resident Lease Agreement (dated 02/20/25) and Identification and Emergency Information (dated 02/21/25). On March 31, 2025, (R1) experienced a fall while receiving home health care from St. Victoria Home Health. The incident was reported by med-tech staff at 6:00 PM. Subsequently, on April 27, 2025, at 6:40 AM, (R1) encountered another fall that caused head injury.

On May 2, 2025, between 09:30 AM and 11:30 AM, the Department interviewed a staff member identified as Staff #1, (S1) the executive director. (S1) confirmed that multiple unwitnessed falls have occurred with (R1) in the past couple of months. (S1) verified the fall dates of March 31, 2025, and April 27, 2025. (S1) claimed that the family representative for (R1) was notified of each incident and received immediate medical attention at St. Mary’s Hospital. It was further stated that (R1) was reassessed with a Resident Assessment on April 29, 2025; however, a fall management plan designed to minimize the risk of falls was not included.

On May 2, 2025, between 11:02 AM and 11:10 AM, the Department interviewed a witness identified as Witness #1 (W1), the family representative for (R1). (W1) reported that staff informed (W1) about (R1)’s recent fall on April 27, 2025, which resulted in several injuries. (W1) also mentioned another fall a few weeks earlier, although (W1) could not provide the exact date and time. That previous fall caused bruises around both eyes and (W1) was notified of it. Both incidents required medical attention at St. Mary’s Hospital.

On May 2, 2025, between 11:35 AM and 11:45 AM, the Department interviewed a resident identified as Resident #1 (R1). (R1) shared a recent experience of a fall in (R1)'s room that resulted in a head injury, mainly because it occurred in a familiar area of the room. (R1) claimed to have prior falls, but the specifics could not be recalled in detail.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20250501115014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 05/02/2025
NARRATIVE
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As a result, Resident #1 (R1)’s Provider Communication Form (dated 04/02/25), Unusual Incident Report (dated 05/02/25), and St. Mary’s Medical Records (dated 04/27/25) confirmed (R1) sustained falls on March 31, 2025, and April 27, 2025, with injuries. A review of (R1)’s Resident Assessment (dated 04/29/25) revealed that (R1) was medically assessed after being hospitalized after a fall incident without a fall management plan. The Department observed (R1)'s wound injuries to the left forehead and bruises on the right inside forearm to confirm injuries from the April 27, 2025, fall incident.

Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Allegation #2: Facility failed to report an incident.

It is alleged that the facility staff failed to report an incident involving resident #1 (R1). According to reports, the staff did not inform licensing authorities about fall incidents concerning (R1) with written incident reports.

On May 2, 2025, between 09:30 AM and 11:30 AM, the Department interviewed a staff member identified as Staff #1, the executive director. (S1) confirmed that multiple unwitnessed falls have occurred with (R1) in the past couple of months. (S1) verified the fall dates of March 31, 2025, and April 27, 2025. (S1) verified that the facility failed to provide a written incident report, Unusual Incident Report LIC 624, for the incident on March 31, 2025, involving (R1) with head injuries from the fall and was admitted to St. Mary’s Hospital.

During the investigation, (S1) also informed the Department of seven incidents with facility residents from April 5, 2025, to April 25, 2025, that were not submitted to Community Care Licensing (CCL) as required according to Title 22 Regulations 87211 Reporting Requirements.



Based on the information gathered, sufficient evidence supports the allegation mentioned above.

Based on observations, interviews, record reviews, and analysis, the preponderance of evidence standard has been met; therefore, the allegations that "Resident had multiple falls in care" and "Facility failed to report an incident." are determined Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.

An exit interview was conducted, and Executive Director Fabiola Marciano was provided with a copy of this report and appeals rights

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20250501115014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87463(b)
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87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.
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Licensee/Administrator shall read "Title 22, Section 87463 Reappraisals” and send a written statement to CCLD a plan of action no later than the POC due date. The plan is due to the CCLD/El Segundo ASC Office by (5/09/25) fax at 424-544-1016 Attn: Ernand Dabuet.
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This requirement is not met as evidenced by: Resident #1 had several falls with no Reappraisal to address the significant health changes with a fall management plan in detail. A plan of action needs to be implemented for the resident due to being at high risk for falls. This poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
05/09/2025
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence...(D) Any incident which threatens the welfare, safety or health of any resident...
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Licensee/Administrator shall read "Title 22, Section 87211 Reporting Requirements" and send a written statement to CCLD a plan of action no later than the POC due date. The plan is due to the CCLD/El Segundo ASC Office by (5/09/25) fax at 424-544-1016 Attn: Ernand Dabuet.
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This requirement is not met as evidenced by:Resident #1 had several falls and failed to submit an SIR to CCL for the 03/31/25 incident. In addition, seven incidents in April 2025 were not submitted to CCL. This poses a potential Health, Safety, or Personal Rights risk to 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4