198602567-8-20-2025-11-AS-JHAD-DKT2JQ-20250822172644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602567
Report Date: 08/20/2025
Date Signed: 08/20/2025 02:34:07 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
06/19/2025 and conducted by Evaluator Zina Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250619142057

FACILITY NAME:	REGENCY PALMS LONG BEACH		FACILITY NUMBER:	198602567
ADMINISTRATOR:	KENIA SANCHEZ PADILLA		FACILITY TYPE:	740
ADDRESS:	117 E 8TH STREET		TELEPHONE:	(562) 432-9260
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY:	91	CENSUS: 75	DATE:	08/20/2025
		UNANNOUNCED	TIME BEGAN:	11:36 AM
MET WITH:	Robert Jakini, Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff mishandled a resident’s medications.
Staff did not properly report incidents involving the residents.

INVESTIGATION FINDINGS:

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This report supersedes ; report dated on 07/10/2025.

On 08/20/2025, at 11:45am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver findings. During today’s visit, LPA met with Robert Jakini (Executive Director) and explained the purpose of the visit.

The investigation consisted of the following: An initial complaint visit was completed by the department on 06/25/2025. During the visit the department conducted interviews with Administrator (A1), Staff (S1-S6) and Residents (R1-R7) between the hours of 9:22 am – 11:47am. On 07/01/2025, the department conducted a subsequent complaint visit to gather additional information and conducted interviews with Staff (S7 - S8).

Report continues on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

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 7

Control Number 11-AS-20250619142057

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: 08/20/2025

NARRATIVE

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The department obtained the following records from the facility: Resident Roster (received 06/25/2025), Staff Roster (dated 06/17/2025), LIC 601 Identification and Emergency Information (for R1) - dated 08/24/2024, LIC 602: Physician Report for RCFE (for R1) - dated 08/19/2024, LIC 603A: Preplacement Appraisal (for R1) - dated 08/24/2024, LIC 624: Unusual Incident/Injury Report - dated 04/13/2025 & faxed 07/01/2025, Staff Schedule (for April 2025), LIC 625: Client/Resident Personal Property and Valuables, Admission Agreement – (dated 08/24/2024), Service Plan (dated 04/24/2025) & Medication Administration Record April 2025 - June 2025.

The investigation revealed the following:

Allegation: Staff mishandled a resident’s medications.
It is alleged that R1's medications had not been delivered to her as scheduled. On 06/25/2025, between 9:00 am - 9:30 am, LPA interviewed A1 who confirmed being aware of some medication errors.

Between 9:22 am - 12:55 pm, LPA interviewed 8 staff: 3 of 8 confirmed the allegation, 3 denied the allegation, and 2 neither confirmed nor denied.

Between 10:53 am - 11:47 am, LPA interviewed 7 residents: 3 out of 7 confirmed the allegation, 3 out of 7 denied the allegation, and 1 gave unclear responses.

On 07/01/2025 between the hours of 11:45am - 1:30pm, the department reviewed R1 medications. The review revealed resident was prescribed medication Miradegron ER 25mg on 6/11/2025 and facility began administering the medication on 6/12/2025. According to the MAR resident was administered the medication daily from 6/12/2025-7/1/2025. The department counted the medication and noted as of 7/1/2025 20 out of 30 pills remained which there should have only been 11 pills remaining if the medication was given daily to R1. Also, LPAs observed the Medication Administration Record (MAR) did not match because the MedTech initial the MAR.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 11-AS-20250619142057

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: 08/20/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff did not properly report incidents involving the residents.
It is alleged that the facility did not report an alleged incident between R1 and another resident on April 13, 2025, to DSS, the Ombudsman, or law enforcement, as would be required by law. On 06/25/2025, between 9:00 am - 9:30 am, LPA interviewed A1 who confirmed the incident occurred and stated upon doing a reporting review, the incident was not reported to the Department and confirmed and provided the proof of incident being faxed on 07/01/2025 when initially the incident occurred on 04/13/2025 .

Between 9:22 am - 12:07 pm, LPA interviewed 8 staff: 4 denied the allegation, and 3 was unsure of the allegation.

Between 10:53 am - 11:47 am, LPA interviewed 7 residents: 1 out of 7 confirmed the allegation, 4 out of 7 denied the allegation, and 2 out of 7 were unsure of the allegation.

LPA conducted a records reviewed for the incident that occurred on 04/13/2025 but noted no evidence that the incident was reported to DSS or the Ombudsman in a timely manner. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).

A copy of this report was provided with the appeals rights to Robert Jakini (Executive Director).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 7

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
06/19/2025 and conducted by Evaluator Zina Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250619142057

FACILITY NAME:	REGENCY PALMS LONG BEACH		FACILITY NUMBER:	198602567
ADMINISTRATOR:	KENIA SANCHEZ PADILLA		FACILITY TYPE:	740
ADDRESS:	117 E 8TH STREET		TELEPHONE:	(562) 432-9260
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY:	91	CENSUS:	DATE:	08/20/2025
		UNANNOUNCED	TIME BEGAN:	11:36 AM
MET WITH:	Robert Jakini, Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff unlawfully evicted a resident.
Staff are retaliating against a resident.

INVESTIGATION FINDINGS:

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This report supersedes ; report dated on 07/10/2025

On 07/10/2025, at 11:45 am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver findings. During today’s visit, LPA met with Robert Jakini (Executive Director) & explained the purpose of the visit.

The investigation consisted of the following: An initial complaint visit was conducted by the Department on 06/25/2025. During the visit interviews were conducted with Administrator (A1), Staff (S1-S6) & Residents (R1-R7) between the hours of 9:22 am – 11:47am. On 07/01/2025, the Department conducted a subsequent complaint visit to gather additional information & conducted interviews with Staff (S7 - S8).The Department requested following records from the facility: Resident Roster (received 06/25/2025), Staff Roster (dated 06/17/2025), all of Resident's 1 (R1's) documents LIC 601 Identification & Emergency Information - dated 08/24/2024, LIC 602: Physician Report for RCFE - dated 08/19/2024, LIC 603A: Preplacement Appraisal - dated 08/24/2024 LIC 624: Unusual Incident/Injury Report - dated 04/13/2025 & faxed 07/01/2025, Staff Schedule (for April 2025), LIC 625: Client/Resident Personal Property & Valuables, Admission Agreement (dated 08/24/2024), Service Plan (dated 04/24/2025) & Medication Administration Record April 2025 - June 2025.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

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 7

Control Number 11-AS-20250619142057

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: 08/20/2025

NARRATIVE

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Allegation: Staff unlawfully evicted a resident.
It is alleged that the facility is attempting to evict Resident 1 (R1) and the eviction notice does not support that R1 engaged in incidents that would make it impossible to live with other residents. On 06/25/2025, between the hours of 9:00 am - 9:30 am, LPA interviewed A1 who denied the allegation and stated that an eviction notice was issued to R1 due to aggressive behaviors, which includes physical aggression toward staff and residents. A1 further stated use of unauthorized video surveillance devices with audio component as a contributing factors which is not allowed at facility as stated the admission agreement which was signed by R1 on 08/26/2024.

Between the hours of 9:22 am - 12:07 pm, LPA interviewed 8 staff regarding the allegation: 5 of 8 staff denied the allegation, 3 out of 8 staff denied being aware the of any eviction notices.

Between 10:53 am - 11:47 am, LPA interviewed residents #1-7, 7 out of 7 residents denied the allegation and 1 out of 7 residents gave unclear responses.

LPA reviewed records and observed the following: an eviction notice was issued to R1 on 05/21/2025 which stated the reason for the eviction was for violating 87224 Eviction Procedures of Title 22 Regulations section 87224(a)(3) “Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement”; 87224(a)(4) “If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.” Based on review of the eviction notice it documents incidents that occurred between R1 and facility staff and residents and documents the use of video surveillance with an audio component being used which violates the facilities admission agreement. LPA revied R1 file and observed a reappraisal was conducted on 4/23/2025 by facility staff. LPA reviewed R1 admission agreement which outlined the general policies of the facility identified in the eviction notice. LPA reviewed the eviction noticed and confirmed it was sent to CCLD within 5 days of issuance and based on LPAs review of the notice it appears to be in compliance with Title 22 regulations.

Based on information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 11-AS-20250619142057

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: 08/20/2025

NARRATIVE

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Allegation: Staff are retaliating against a resident. It is alleged that the proposed eviction is retaliatory.
On 06/25/2025, between 9:00 am - 9:30 am, LPA interviewed A1 who denied the allegation and stated that staff are in-serviced regularly to ensure fair treatment and follow-up on family complaints, and that decisions are based on care needs, safety, and facility policy.

Between 9:22 am - 12:07 pm, LPA interviewed 8 staff: 8 out of 8 denied the allegation.

Between 10:53 am - 11:47 am, LPA interviewed 7 residents: 7 out of 7 denied the allegation.

LPA did not observe any documentation or evidence supporting claims of retaliation. Based on the information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

No deficiencies were cited for the allegations above.

An exit interview was conducted, and a copy of this report was provided to Robert Jakini (Executive Director).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 11-AS-20250619142057

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: 08/20/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/22/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	ncidental Medical and Dental Care (a) A plan for incidental medical & dental care shall be developed by each facility. The plan shall encourage routine medical & dental care & . . assistance in obtaining such care, by compliance with ...: (4) the licensee shall assist residents with self-administered	1 2 3 4 5 6 7	The licensee will re-training and re-certify all Med-Tech on administering medication to all the residents. The licensee will also conduct daily audits for Medication Administration for the next 30 days.
	8 9 10 11 12 13 14	medications as needed. This requirement was not met as evidence by. Based on observation & record review, staff failed to ensure medication for (R1) was not administered as per the doctor's order. This poses a potential health & safety risk to residents in care.	8 9 10 11 12 13 14	The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.
Type B 08/27/2025 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	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...	1 2 3 4 5 6 7	The facility will submit the LIC624 Unusual Incident/Injury Report to the Department of the incident that occurred on 04/13/2025. Also the facility will training all staff on reporting requirements per Title 22 regulation.
	8 9 10 11 12 13 14	Based on conducted interviews & records review the licensee failed to report incidents that occurred on 04/13/2025 to licensing in accordance with Title 22 regulation. This poses a potential Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14	The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

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: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC9099 (FAS) - (06/04)

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