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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602567
Report Date: 11/05/2021
Date Signed: 11/06/2021 09:14:04 AM



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
11/01/2021 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211101104748
FACILITY NAME:REGENCY PALMS LONG BEACHFACILITY NUMBER:
198602567
ADMINISTRATOR:CARLA MARIANOFACILITY TYPE:
740
ADDRESS:117 E 8TH STREETTELEPHONE:
(562) 432-9260
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY:91CENSUS: 52DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Carla Mariano5TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident sustained an injury due to an unwitnessed fall.
Resident's call button is not accessible.
INVESTIGATION FINDINGS:
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On 11/5/2021 at 8:25 a.m., Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegations listed above. LPA was allowed entry into the facility by Administrator Carla Mariano. LPA explained to Ms. Mariano the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (5) staff members and (5) residents on 11/5/21. In addition, on 11/5/21, LPA and Ms. Mariano conducted an inspection, for health and safety of the facilities’ physical plant, and food supply, and also inspected all the facility resident room call button box stations. LPA also reviewed the following documents provided by Regency Palms Long Beach administrator Carla Mariano: LIC 500-staff roster, client roster, staff schedule, Incident Reports from October 2021 to present, List of Caregivers work hours on assigned floors, Internal staff incident reports from October 2021 to present, Staff NOC shift duties, October NOC shift facility room check reports, R1 case notes, R1 physician report, R1 service care and R1 medical documents.

Report continued on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
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 6
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
11/01/2021 and conducted by Evaluator Susan Campos
COMPLAINT CONTROL NUMBER: 11-AS-20211101104748

FACILITY NAME:REGENCY PALMS LONG BEACHFACILITY NUMBER:
198602567
ADMINISTRATOR:CARLA MARIANOFACILITY TYPE:
740
ADDRESS:117 E 8TH STREETTELEPHONE:
(562) 432-9260
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY:91CENSUS: 52DATE:
11/05/2021
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Carla Mariano5TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
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9
Facility is short staffed.
INVESTIGATION FINDINGS:
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On 11/5/2021 at 8:25 a.m., Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegations listed above. LPA was allowed entry into the facility by Administrator Carla Mariano. LPA explained to Ms. Mariano the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (5) staff members and (5) residents on 11/5/21. In addition, on 11/5/21, LPA and Ms. Mariano conducted an inspection, for health and safety of the facilities’ physical plant, and food supply, and also inspected all facility resident room call button box stations. LPA also reviewed the following documents provided by Regency Palms Long Beach administrator Carla Mariano: LIC 500-staff roster, client roster, staff schedule, Incident Reports from October 2021 to present, List Caregivers work hours on assigned floors, Internal staff incident reports from October 2021 to present, Staff NOC shift duties, October NOC shift facility room check reports, R1 case notes, R1 physician report, R1 service care and R1 medical documents.

Report continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20211101104748
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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 11/05/2021
NARRATIVE
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Investigation

Allegation: Staff is short staffed

The investigation revealed, per LPA interviews, with (5) staff members, and (5) residents from the Regency Palms Long Beach facility and review of facility documents, that the Regency Palms Long Beach facility is not short staffed. The investigation revealed, per LPA interviews, with (5) staff members, and (5) residents from the Regency Palms Long Beach facility and review of facility documents, that the Regency Palms Long Beach is not short staffed. LPA interviewed S1, and the LPA was informed that the facility has two caregivers, assigned to each floor, for day and night shifts, (except 2, 6 and 7 floors that have 1 assigned caregiver), and one caregiver during NOC work shift assigned to each floor. Also, S1 stated that the Med-Tech on duty, with assigned caregivers, also supervises the caregivers, and makes sure that the residents are cared for. Furthermore, the caregivers sign off and endorse to the Med-Tech, once their work shift is completed, and verify that all their residents have been checked, and do not need assistance. S1 also stated that the management team do rounds in the facility, and check the residents, as does the Med-Tech, conduct rounds to verify that the resident’s needs are met, and other concerns do not need to be addressed. LPA interviewed 5 staff members, and 5 of 5 staff members informed the LPA, that staff members check on the residents, to ensure that there are no issues, and also 5 of 5 staff members informed the LPA that there is a staff endorsement process, at the end of a work shift, confirming that all residents have been checked, and that there are no issues with the residents. In addition, 5 of 5 staff members informed the LPA, that there is enough staff members to cover, the resident needs, on every work shift, and also that the Med-Tech and managers, support the caregivers if there is a need. The LPA interviewed 5 residents, and 4 of 5 residents informed, the LPA, that the caregivers assist them when needed, and also 4 of 5 residents informed the LPA, that the caregivers are available when needed.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Facility is short staffed ”.

Although the allegations 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 Carla Mariano, Administrator, and a hard copy of a LIC 9099 was provided.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20211101104748
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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 11/05/2021
NARRATIVE
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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. A telephonic exit interview was conducted with Carla Mariano, Administrator and a hard copy of a LIC 9099 and LIC 9099D was provided.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20211101104748
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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 11/05/2021
NARRATIVE
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Investigation

Allegation: Resident sustained an injury due to an unwitnessed fall.

The investigation revealed, per LPA interviews, with (5) staff members, and (5) residents from the Regency Palms Long Beach facility, and review of facility documents, that a Regency Palms Long Beach facility resident sustained an injury due to an unwitnessed fall .

LPA interviewed S1, and the LPA was informed by S1, that R1 had sustained an injury on 10/27/21, at approximately 3:15 am, as a result, of a fall in R1’s room. R1 was immediately transported to the hospital, for medical follow up, and returned to the facility on the same day. S1 stated that R1 has bruises on the face and neck, and also a hematoma on the forehead. S1 informed LPA that R1 states that is not in pain or discomfort, and has returned to normal activities. S1 submitted to licensing incident report regarding the event prior to 7 day reporting deadline.

On 11/5/21, at 9:30 am, LPA was informed by S1, that R1 fell in R1’s room, and sustained face and neck bruising and a hematoma on the forehead.

Based on information gathered, LPA did find sufficient evidence to support allegation " Resident sustained an injury due to an unwitnessed fall ”.

Allegation: Resident's call button is not accessible

The investigation revealed, per LPA interviews, with (5) staff members, and (5) residents from the Regency Palms Long Beach facility, and review of facility documents, that R1’s call button is not accessible. In addition, S1 and LPA, inspected the facility resident’s room and bathroom call button boxes. S1 and LPA observed, 11 Call button boxes, with missing pull cords. In addition, the LPA pulled the cord on Room 401, and observed that a caregiver responded, to the call, in 5 minutes.

On 11/5/21, between 10:20 a.m. – 11:40 a.m., LPA observed that 11 resident call box stations did not have an attached pull cord to activate the call box.

Based on information gathered, LPA did find sufficient evidence to support the allegation " Resident's call button is not accessible ”.

Report continued on LIC 9099C

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20211101104748
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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited
CCR
87303(i)(1)(A)
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87303(i)(1)(A)Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria:(1)All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:(A)Operate from each resident's living unit.
This requirement is not met as evidenced by:
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Administrator provided LPA with work order report dated 11/5/21, stating that the 11 identified facility resident room call box stations have each been installed with a pull cord on 11/5/21
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Based on interviews, and record review, the licensee failed to ensure the safety of resident, on 11/5/21, LPA and S1 observed that 11 facility resident room call box stations did not have a pull cord which posed a potential health risk to residents in care.
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Type B
11/30/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2)Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Administrator will fax to LPA a copy of the Regency Palms Long Beach facility resident fall prevention plan, and also a copy of the fall prevention plan staff training sign in sheets.

POC Due Date is 11/30/21
LPA Fax Number (323)981-1781
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Based on interviews, and record review, on 11/5/21, S1 informed LPA that R1, fell in resident's room, and sustained injury 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.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6