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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000059
Report Date: 08/14/2024
Date Signed: 08/14/2024 02:33:32 PM


Document Has Been Signed on 08/14/2024 02:33 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:DENNIS ROBENIOLFACILITY TYPE:
740
ADDRESS:1750 W. LA HABRA BLVD.TELEPHONE:
(714) 441-1164
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:168CENSUS: 89DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:35 AM
MET WITH:Jorge GarciaTIME COMPLETED:
02:48 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Maintenance Director (MD) Jorge Garcia and discussed the purpose of the inspection. Administrator (AD) Ashley Willett arrived during the inspection.

LPA reviewed Infection Control requirements. At about 8:00AM, LPA and MD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication rooms and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, two-story building with a delayed egress memory care unit on the second floor, a commercial kitchen and large dining room on the first floor, medication rooms on both floors, and resident rooms on all floors, along with multiple common areas, storage rooms, and a large central courtyard and a smaller courtyard dedicated to memory care with shaded seating for residents. There are a total of 86 resident rooms. Resident Bedrooms: the 12 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 12 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 110 degrees F and 117 degrees in the 9 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication rooms: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid and are past due. At about 10:00AM, LPA reviewed 6 resident files and 6 staff files, interviewed 6 residents and 6 staff, and inspected medications for 6 residents. Facility does not handle resident money.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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 08/14/2024 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 306000059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documents, the administrator was changed in October 2023 but not all documents LPA requested were provided and the administrator still has not been updated, which poses a potential safety risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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Licensee stated they will submit all required documents to LPA by POC due date.
Type B
Section Cited
CCR
87156(a)


87156 Licensing Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on documents, the licensee has not paid their licensing fees for multiple years which are now past due, which poses a potential personal rights risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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Licensee stated they will pay the licensing fees and submit proof to LPA by POC due date.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2024 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 306000059

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)

87411 Personnel Requirements – General …(c) … (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on documents, the licensee did not ensure S1, S2, and S3 had current first aid training as their certificates were expired, which poses a potential health risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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Licensee stated they will have these staff renew their first aid training and submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87705(c)(5)


87705 Care of Persons with Dementia … (c) … (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually... This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on documents, the licensee did not ensure R1, who has dementia per their most recent Physician’s Report dated 01/30/23, received an annual medical assessment, which poses a potential health risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
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Licensee stated they will have a new physicians report completed for R1 and conduct an audit of all residents to ensure residents with dementia are having physician’s reports and reappraisals completed annually and will submit proof to LPA by POC due date.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 306000059
VISIT DATE: 08/14/2024
NARRATIVE
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During the inspection, LPA and AD observed the following: based on documents, the administrator was changed in October 2023 but not all documents LPA requested were provided and the administrator still has not been updated; based on documents, the licensee has not paid their licensing fees for multiple years which are now past due; based on documents, the licensee did not ensure S1, S2, and S3 had current first aid training as their certificates were expired; and based on documents, the licensee did not ensure R1, who has dementia per their most recent Physician’s Report dated 01/30/23, received an annual medical assessment.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights 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: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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