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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700923
Report Date: 07/19/2021
Date Signed: 07/19/2021 02:57:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:REGENCY PLACEFACILITY NUMBER:
342700923
ADMINISTRATOR:HURRIANKO, HARUMIFACILITY TYPE:
740
ADDRESS:8190 ARROYO VISTA DRIVETELEPHONE:
(530) 242-8300
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:85CENSUS: 74DATE:
07/19/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Elizabeth CruzTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Suong Teh arrived at this facility announced on 07/19/2021 at 01:30 PM to conduct a pre-licensing inspection. LPAs met with the facility designated Administrator Elizabeth Cruz and explained the purpose of the visit. The facility designated Administrator Elizabeth Cruz assisted with today’s visit.
NOTE: Currently the STD 850 Fire Clearance is cleared for 61 non-ambulatory, however, the LIC 200 requested for 61 non-ambulatory. Elizabeth will re-submit a new LIC 200 to CAB.

Administrator Elizabeth Cruz holds a current certificate # 6056444740 which will expire on 09/03/2021. The LPA Teh toured and inspected the physical plant inside and outside with the administrator Elizabeth Cruz to ensure there were no health and safety concerns on 07/19/2021 at 01:30 PM. LPA observed there are currently 74 residents in care at this time.

The facility had Covid-19 posting throughout the facility. The facility had a mitigation plan completed and provided it to LPA Teh for approval on 07/18/2021. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

LPAs observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. The Salon room and activity room were reviewed to make sure that all components were functional and in good repair at this time.



Continued on 809-C
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: REGENCY PLACE
FACILITY NUMBER: 342700923
VISIT DATE: 07/19/2021
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A review was conducted of the apartment sizes and different layouts. The med room located primarily on the in the assisted living and was toured. Kitchen pantry and walk-in freezer was toured for adequate food supplies and storage. LPA observed required furniture and lighting throughout the facility. The hot water temperature was measured at 110*F during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility measured at 81*F which was within the required range of 68-85*F.

LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kits were available in the kitchen and med rooms. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPAs observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the facility were in good repair. LPAs observed the area where the staff and resident files were locked and readily available for review.



Based on a review of this facility during this Prelicensing visit, it was determined that this facility was found to be in compliance at this time. Component III was conducted.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
LIC809 (FAS) - (06/04)
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