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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602567
Report Date: 12/17/2024
Date Signed: 12/17/2024 04:16:59 PM

Document Has Been Signed on 12/17/2024 04:16 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:REGENCY PALMS LONG BEACHFACILITY NUMBER:
198602567
ADMINISTRATOR/
DIRECTOR:		KENIA SANCHEZ PADILLAFACILITY TYPE:
740
ADDRESS:117 E 8TH STREETTELEPHONE:
(562) 432-9260
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY: 91CENSUS: 69DATE:
12/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Executive Director, Fabiola MarcianoTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 12/17/2024, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted a Case Management visit at this facility to deliver an additional deficiency regarding COMPLAINT CONTROL NUMBER: 11-AS-20241125165223. CCLD staff met with the Executive Director, Fabiola Marciano and explained the purpose of the visit.

The investigation revealed the following:
On 11/20/2024, Staff 1 (S1) handled a resident in a rough manner.
Interviews conducted revealed the following:
Two witnesses indicated that they saw S1 handle a resident in a rough manner.
The Resident Care Coordinator was informed of the incident on 11/22/2024.
The Executive Director was informed of the incident on 11/22/2024.
Both the Resident Care Coordinator and the Executive Director indicated that they did not submit an Unusual Incident/Injury Report to CCLD.
Records reviewed revealed the following:
On 12/03/2024, the Department reviewed CCLD’s El Segundo’s Regional Office files and did not find an Unusual Incident/Injury Report regarding the incident above.

A deficiency is being cited based on interviews conducted and record review in accordance with the California Code of Regulations, Title 22. A deficiency regarding Reporting Requirements. An exit interview was conducted, and a copy of this report was left with the Executive Director along with their appeal rights.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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Document Has Been Signed on 12/17/2024 04:16 PM - It Cannot Be Edited


Created By: Socorro Leandro On 12/17/2024 at 01:36 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2025
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 as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement was not meet by evidence by:
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The Executive Director has agreed to re-read CCR87211 and follow Reporting Requirements, create a plan to follow Reporting Requirements, and retrain staff on how to submit written reports to licensing.
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Based on interviews conducted and record review, the licensee did not comply with section cited above by not submitting a written report to the licensing agency within seven days of the incident that occurred on 11/20/2024.
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The Executive Director has agreed tol submit an Unusual Incident Report to CCLD regarding the incident that occured on 11/20/2024.

The licensee will email proof of correction to Socorro.Leandro@dss.ca.gov

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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Socorro Leandro
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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