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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000059
Report Date: 07/25/2022
Date Signed: 07/25/2022 12:21:24 PM


Document Has Been Signed on 07/25/2022 12:21 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: 94DATE:
07/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rachelle ReyesTIME COMPLETED:
12:35 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 death report received in the Orange County Regional Office (OCRO) on 06/28/22 regarding Resident #1 (R1). LPA met with Administrator (AD) Rachelle Reyes and discussed the purpose of the inspection.
The death report (with additional details and clarification from today’s interviews) stated that on 06/27/22 at 4:20 PM, a caregiver observed R1 in bed complaining of not feeling well and called Staff #1(S1) and Staff #2 (S2). S1 and S2 checked R1 and observed R1 complaining of body aches and spitting up small amounts of saliva. R1 was laid back on the bed and S1 and S2 went to go get R1’s medication. At 4:35 PM, Staff #3 (S3) checked on R1, found R1 on the floor, and called S1. S1 assessed R1 and noted R1 was unresponsive and pale. Facility staff called 911. S1 performed CPR until paramedics arrived and the paramedics continued CPR. The police also arrived at around the same time as the paramedics. R1 was pronounced dead at 5:08 PM by the paramedics.
During today’s inspection, LPA interviewed AD and staff and requested copies of R1’s Resident File, Medical File, Charting Records, and any other pertinent records. AD agreed to email these documents to LPA by COB 7/26/22. Staff interviewed stated R1 was left alone after being laid back on the bed because, other than complaining about pain, R1 did not appear to be in a medical emergency and staff focused on getting R1 their medications. Staff interviewed also stated that R1 had not recently had any changes in condition, changes in medication, or new symptoms or complaints and that R1’s passing was unexpected as R1 had been doing well and was physically strong leading up to the incident. Staff interviewed stated that it was possible that S3 was also the original caregiver who observed R1 at 4:20 PM. AD will confirm whether or not that is true.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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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