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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000059
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:35:26 PM


Document Has Been Signed on 03/29/2022 03:35 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PARK REGENCY RETIREMENT CENTERFACILITY NUMBER:
306000059
ADMINISTRATOR:ROSALIE SULLIVANFACILITY TYPE:
740
ADDRESS:1750 W. LA HABRA BLVD.TELEPHONE:
(714) 441-1164
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:168CENSUS: 88DATE:
03/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Rachelle ReyesTIME COMPLETED:
03:50 PM
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This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office on 02/24/2022 regarding Resident #1 (R1). LPA met with Administrator (AD) Rachelle Reyes and discussed the purpose of the inspection.

The incident report stated that on 02/23/2022 R1’s family member reported to facility staff that R1 had stated that a caregiver had hit R1 on 3 different occasions. The facility interviewed R1, reported the incident to the La Habra Police Department, and suspended the suspected caregiver, Staff #1 (S1). The La Habra Police Department obtained statements at the facility on 02/23/2022.

During today’s inspection, LPA toured the facility with AD, interviewed AD, staff, and residents, conducted a health and safety check on R1, and requested and reviewed pertinent records. S1 was terminated as of 03/01/2022. LPA observed R1 to be in good health and good spirits at the facility.

Facility representative was advised that at this time further investigation may be required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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