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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300603257
Report Date: 07/10/2025
Date Signed: 07/10/2025 03:31:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/27/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20250527184045
FACILITY NAME:REGENTS POINTFACILITY NUMBER:
300603257
ADMINISTRATOR:FORNEY, MELINDA MFACILITY TYPE:
741
ADDRESS:19191 HARVARD AVENUETELEPHONE:
(949) 854-9500
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY:399CENSUS: 44DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Sheila WeathersTIME COMPLETED:
03:46 PM
ALLEGATION(S):
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Staff did not give resident medication as prescribed
Staff did not keep resident's authorized person informed about the resident's care
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.

The Department received a complaint on May 27, 2025, and the initial 10-day visit was conducted on June 6, 2025. The Department obtained copies of documents including in-service staff training, physician’s report, medication administration record, and admission agreement for Resident 1 (R1). It was alleged staff did not give resident medication as prescribed and staff did not keep resident’s authorized person informed about the resident’s care. During the investigation, LPA conducted interviews with staff and reviewed records obtained.

The investigation determined as follows: Regarding the allegation staff did not give resident medication as prescribed, it was reported R1 had missed medication administration on more than 148 instances.

Continued on 9099-C dated on 07/10/2025.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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 3
Control Number 22-AS-20250527184045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: REGENTS POINT
FACILITY NUMBER: 300603257
VISIT DATE: 07/10/2025
NARRATIVE
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LPA interviews with three out of four staff stated R1 did not receive one medication dosage on the evening of March 2, 2025 because R1 was sleeping. The remaining one out of four staff was unsure. In addition, two out of four staff stated R1 did not receive one medication dosage on May 14, 2024 because R1 was sleeping. The remaining two out four staff were unsure. LPA records review of R1’s medication record confirm R1 did not receive one medication dosage in the evening of March 2, 2025 and May 14, 2024. In addition, LPA records review of R1’s medication record from October 2023 through June 2025 showed multiple instances of various medications not marked as being administered. Three out four staff stated that there are times when staff will forget to mark medications as administered in their medication tracking system. LPA reviewed in-service training completed on May 20, 2025 focused on medication documentation for staff involved in administrating medications. LPA observed R1’s medications in the medication room.

Regarding the allegation staff did not keep resident's authorized person informed about the resident's care, it was reported the facility never told the responsible person (RP) when medication was not provided to R1. LPA interviews with three out of four staff stated RP was informed verbally on March 3, 2025 when R1 missed one medication dosage on March 2, 2025 during a visit by RP. The remaining one out of four staff was unsure. One out of four staff stated RP was not informed when R1 missed one medication dosage on May 14, 2024. The remaining three out of four staff were unsure. LPA review of R1’s medication record documented refusals and in some cases, documented RP’s presence during R1’s medication refusals. Three out of four staff stated responsible parties are usually informed about a resident’s refusal of medications. The remaining one out of four staff stated they do not notify anyone unless it’s a recurring issue. The facility did not provide any documented evidence of informing RP about R1’s refusal of medications.

Based on LPA interviews and record review, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250527184045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: REGENTS POINT
FACILITY NUMBER: 300603257
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2025
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care
Once ordered by the physician the medication is given according to the physician's directions.
The requirement was not met as evidenced by:
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Facility has completed in-service staff training to correctly mark medications as administered in the medication tracking system. In service training started on 5/20/2025 and is ongoing. Facilty provided copy of in-service training to LPA during initial visit.
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The facility did not give medication according to the physician's directions.
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Type B
07/24/2025
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Reporting Requirements
A written report shall be submitted ... to the person responsible for the resident ... of the occurrence of...Any incident which threatens the welfare, safety or health of any resident... The requirement was not met as evidenced by:
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Facility has completed in-service staff training to notify responsible party and physician for any missed medications. In service training started on 5/20/2025 and is ongoing. Facilty provided copy of in-service training to LPA during initial visit.
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The facility did not inform the responsible person for medication not administered to Resident 1.
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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: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3