342701107-10-8-2024-27-AS-KHOS-DCXRN5-20250115120944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701107
Report Date: 10/08/2024
Date Signed: 10/08/2024 01:56:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/02/2024 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20240402153118

FACILITY NAME:	REGENCY PLACE		FACILITY NUMBER:	342701107
ADMINISTRATOR:	DAMION E. ANDERSON		FACILITY TYPE:	740
ADDRESS:	8190 ARROYO VISTA DRIVE		TELEPHONE:	(916) 681-7800
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	61	CENSUS: 50	DATE:	10/08/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Alvin Gaoat		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not follow proper reporting requirements

INVESTIGATION FINDINGS:

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On 10/8/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to deliver the findings for a complaint investigation regarding the allegation above. LPA met with Resident Services Director Alvin Gaoat and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on interviews and records review, it was learned that the facility did not follow the reporting requirement as required. The following incidents were not reported: On 5/22/2022, resident (R1) was rushed to the hospital and diagnosed with an UTI. On 9/23/2022, R1 was diagnosed with a fracture on the right pelvic hip at Sacramento Methodist Hospital. There were no incident reports found of any unwitnessed falls related to this injury. On 12/1/2022, R1’s family discovered a laceration on the R1’s right knee. Based on records review, there were no incident reports pertaining to the incident above being sent to Licensing.

As a result of this investigation, LPA finds the allegation above to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview conducted. A copy of this report, LIC 9099-D, and appeal rights were provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 27-AS-20240402153118

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REGENCY PLACE	FACILITY NUMBER: 342701107
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/08/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/22/2024 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211(a)(1) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require. A written report shall be submitted to the licensing agency and to the person responsible… This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to conduct an in-service staff training on reporting requirements. Licensee further agrees to send the Department a copy of a sign-in sheet for this training by the POC due date. Licensee shall review section 87211 and submit a statement acknowledging understanding of regulations by POC due date.
	8 9 10 11 12 13 14	Based on observations and records review, the licensee did not ensure to report incidents via a written report or verbal communication to community care licensing, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/02/2024 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20240402153118

FACILITY NAME:	REGENCY PLACE		FACILITY NUMBER:	342701107
ADMINISTRATOR:	DAMION E. ANDERSON		FACILITY TYPE:	740
ADDRESS:	8190 ARROYO VISTA DRIVE		TELEPHONE:	(916) 681-7800
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	61	CENSUS: 50	DATE:	10/08/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Alvin Gaoat		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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9

Staff did not ensure resident’s incontinence needs were met in a timely manner.
Staff gave resident discontinued medications.

INVESTIGATION FINDINGS:

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On 10/8/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to deliver the findings for a complaint investigation regarding the allegations above. LPA met with Resident Services Director Alvin Gaoat and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on interviews and records review, there is not a preponderance of evidence to prove the allegations mentioned above. Regarding the allegation, “Staff did not ensure resident’s incontinence needs were met in a timely manner”, LPA obtained the following information through interviews and records review. Based on staff interviews, staff stated that resident (R1) incontinence needs were met in a timely manner. Based on interviews and records review, there is no evidence found to show R1was left soiled for an extended period of time.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20240402153118

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REGENCY PLACE	FACILITY NUMBER: 342701107
	VISIT DATE: 10/08/2024

NARRATIVE

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Regarding the allegation, “Staff gave resident discontinued medications”, LPA obtained the following information through interviews and records review. Based on records review, it was learned that Morphine and Lorazepam were PRN and were not administered to R1. A review of R1’s Medication Administration Record (MAR) revealed that Morphine and Lorazepam were not administered to R1.

As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and a copy of the report was provided upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4