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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602567
Report Date: 10/24/2025
Date Signed: 10/24/2025 03:44:22 PM

Document Has Been Signed on 10/24/2025 03:44 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:REGENCY PALMS LONG BEACHFACILITY NUMBER:
198602567
ADMINISTRATOR/
DIRECTOR:		ROBERT JAKINIFACILITY TYPE:
740
ADDRESS:117 E 8TH STREETTELEPHONE:
(562) 432-9260
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY: 91CENSUS: 71DATE:
10/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:16 AM
MET WITH:Robert Jakini, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 10/24/2025 at 08:20am, Licensing Program Analysts (LPAs) Zina Brown and Lizeth Villegas conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPAs met with Robert Jakini (Administrator) and the purpose of the visit was discussed. Facility is licensed to serve 91 non-ambulatory residents of which 10 may be bedridden, delay egress observed to be functional in memory care units which are floors, 2-4. There are 32 residents are diagnosed with dementia, 53 residents receiving home health and 10 residents receiving hospice care services. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facility does not handle any of the residents’ money.

The facility has a current administrator certificate (#7010468740) for Robert Jakini (Administrator) valid from 07/24/2025 - 07/23/2027. Administrator provided with upcoming annual fees info. The facility has liability insurance with (Ascot Insurance Company - NAIC # 23752) with an effective date as of (11/01/2024 - 11/05/2025 ) with each occurrence at $1,000,000 and general aggregate at $2,000,000 (policy # MAPL241000320203).

LPA's Brown and Villegas conducted a records review of (8) resident records, (8) staff records, and the facility disaster plan. Facility disaster plan is observed to be current and in compliance with Title 22 regulations at the time of visit. LPA Villegas conducted a review of (8) Resident Medication Administration Records. There are 2 medication carts that are used.

Report continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 10/24/2025
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The facility is a 10 story building with eight (8) rooms on each floor, a basement, administrative offices on the first floor, rooftop patio. For the memory care, the facility is allowed to 13 beds and 13 residents. Also on the memory care floors #2 - #4 there are egress doors. LPA Villegas toured the resident bedrooms that had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between (105 F.-120 F.). Pull cords were observed. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.



LPA observed the following not in compliance:
On 10/25/2025, LPA observed 2 medication discrepancies for Resident 6 (R6) and Resident (R7).

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, and citations were issued at this time.

Exit interview was held and a copy of the Facility Evaluation Report with Appeal Rights were provided to Robert Jakini (Administrator)

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2025 03:44 PM - It Cannot Be Edited


Created By: Zina Brown On 10/24/2025 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
Deficient Practice Statement
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Based on interview andrecord review, the licensee/Executive Director did not comply with the section cited above as the medication administration record (MAR) indicating that medication(s) were given to residents #6-7 as prescribed, however LPA observed medication still to be in the bubble pack which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Licensee/Executive Director to conduct Inservice with all staff who assist residents with medication administration. In service will include the importance of documenting medications given and/or refused. LPA Brown to receive proof of in-service by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Zina Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2025


LIC809 (FAS) - (06/04)
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