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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881303
Report Date: 11/09/2023
Date Signed: 11/09/2023 05:11:46 PM


Document Has Been Signed on 11/09/2023 05:11 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:REGENCY RANCH CARE HOMEFACILITY NUMBER:
331881303
ADMINISTRATOR:CALMA, MARICELFACILITY TYPE:
740
ADDRESS:16005 REGENCY RANCH RDTELEPHONE:
(951) 776-3289
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: 5DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Staff, Madeline VelascoTIME COMPLETED:
05:20 PM
NARRATIVE
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On 11/8/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with staff Madeline Velasco and spoke with administrator Maricel Calma over the phone\. Both were informed of the purpose of the visit. At the time of the visit there was (2) staff and (5) residents present.

The facility is a one story home with attached garage. No firearms or pools are present at the facility. The home has (5) bedrooms and (3) bathrooms. The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed hand washing stations with hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train staff on infection control guidelines.



Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide were operational, and the hot water temperature was recorded at 118F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: REGENCY RANCH CARE HOME
FACILITY NUMBER: 331881303
VISIT DATE: 11/09/2023
NARRATIVE
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Record Review and Resident/Staff Files: LPA reviewed staff files and training. One staff file was not available for Staff #1 (S1). S1 also does not have a documented criminal record clearance with the department. Both staff in shift did not have proof of a current CPR certification. These issues were documented on deficiency page and plan of correction was created with administrator. Civil penalty is being assessed for S1 at $500, and removal was conducted during the visit. Resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in cabinet next to the kitchen. LPA reviewed resident medications, all of which were accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The facility's last fire drill was conducted 8/1/23.

An exit interview was conducted where a copy of this report, along with deficiency pages, appeal rights, and civil penalty was reviewed and provided to staff, Madeline Velasco.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/09/2023 05:11 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: REGENCY RANCH CARE HOME
FACILITY NUMBER: 331881303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with (2) of (2) staff on shift who did not have proof of a current CPR certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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The licensee agreed to send the LPA proof of updated training for Staff #2 (S2). This is due by the POC due date.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with (1) of (2) staff who did not have their personell record to audit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2023
Plan of Correction
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The licensee agreed to send the LPA proof of a completed personnel record for Staff #1 (S1) by the 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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 11/09/2023 05:11 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: REGENCY RANCH CARE HOME
FACILITY NUMBER: 331881303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with Staff #1 (S1) who did not poses a cleared background check or transfer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2023
Plan of Correction
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The licensee had S1 removed immediately during the visit and LPA witnessed S1 leave. Licensee agreed to send the LPA a written statement indicating they understand the section cited above. This is due by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4