342701107-10-17-2025-27-AS-SRIN-DMR3SW-20251023183101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701107
Report Date: 10/17/2025
Date Signed: 10/17/2025 10:09:46 AM

Unsubstantiated

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
12/16/2024 and conducted by Evaluator Arvin Villanueva

COMPLAINT CONTROL NUMBER: 27-AS-20241216143525

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: 52	DATE:	10/17/2025
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Damion Anderson		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Staff left resident in soiled briefs for extended periods.
Staff left resident in the same clothing for extended periods.
Staff did not meet resident’s dietary needs resulting in weight loss.
Staff consumed resident’s personal food items.

INVESTIGATION FINDINGS:

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On 10/17/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced to conduct a follow up complaint visit regarding the allegations noted above. LPA met with Executive Director/Administrator, Damion Anderson (AD), and stated the purpose of the visit.

Allegation - staff left resident in soiled briefs for extended periods: The investigation into this allegation consisted of record reviews, interviews and observation.
Record showed that Resident 1 (R1) was diagnosed with Alzheimer’s dementia and is noted in physician reports dated 11/14/24 and 11/22/23 as being dependent on staff for all activities of daily living (ADLs), including toileting. R1 was assessed to be incontinent of bowel and bladder. Facility assessments dated 11/30/23 and 8/1/24 show that R1 requires total assistance with toileting and receives incontinence care with extensive checks and/or changes daily. R1 is also checked on at least four times per shift.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025

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 5

Control Number 27-AS-20241216143525

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: 10/17/2025

NARRATIVE

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A review of hospice care notes from August to December 2024 shows R1 receives hygiene care, including showers, from a home health aide at least 2 times per week. No concerns were noted regarding R1 being left in soiled briefs or wearing the same clothing for extended periods. Additionally, hospice provided staff training on 7/21/24, covering incontinence care, hydration, nutrition, and skin care.

Care notes from December 2023 to December 2024 document instances where R1 refused hygiene or care. R1 has been known to engage in behaviors such as smearing feces, which required housekeeping to change bed linens. These incidents were recorded as being addressed by staff.

Interviews with staff consistently confirmed that residents are checked frequently, usually every two hours, and that incontinence care is part of the routine. Staff stated they have not witnessed any residents, including R1, being left in soiled briefs for extended periods. One staff stated that clothing and hygiene are addressed during regular care or sooner if needed.

Resident interviews did not support the allegation. One resident stated they receives assistance when requested and did not confirm being left in soiled briefs. Another resident shared that staff assist them with changing adult brief at least twice per shift and that help is given in a timely manner. Another resident did not have any personal experience to share regarding the allegation.

During observation, LPA tested a resident’s call system and noted a staff response time of approximately five minutes, suggesting staff are available and responsive to residents’ needs.

Based on all gathered information, including documentation, observations, and statements from staff and residents, there is insufficient evidence to support the claim that staff left residents in soiled briefs for extended periods. Therefore, the allegation is UNSUBSTANTIATED.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20241216143525

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: 10/17/2025

NARRATIVE

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Allegation - staff left resident in the same clothing for extended periods: The investigation into this allegation consisted of interviews, record reviews and observation.
R1’s care records show that R1’s needs changed over time due to diagnosis of Alzheimer’s disease and dementia. According to the 11/30/2023 Needs and Services Plan, R1 required standby assistance with bathing twice a week and help preparing clothing. R1 was also noted to wander but could dress and move independently. However, review of 8/1/2024 Resident Assessment showed increased care needs: R1 required one-person total assistance for bathing and dressing, along with frequent toileting assistance and checks throughout the day. Hospice care was also involved, with home health aides providing hygiene care at least three times a week.
R1’s Physician Report dated 11/14/2024 confirmed that R1 could no longer independently bathe, dress, toilet, or feed. Hospice records from August to December 2024 showed no noted concerns about R1 being left in soiled clothing or wearing the same clothes for long periods. Additionally, on 7/21/2024, hospice provided training to staff on topics including skin care, hygiene, and incontinence care.
A review of R1’s care notes from December 2023 to December 2024 showed that R1 occasionally refused meals, medications, and hygiene care. There were also reports of behaviors such as smearing feces, requiring bed linen changes.
Interviews with residents did not reveal any concerns about hygiene or clothing. None of them reported witnessing any resident being left in the same clothing for too long. They confirmed that staff provide assistance, although they wished there were more staff available.
Staff interviews were consistent in stating that residents are checked frequently—every two hours or more depending on the shift. They also stated that clothing is changed during hygiene routines or when clothes are dirty. Specifically regarding R1, one staff shared that R1 required two-person assistance for care and was often provided fresh clothing. Staff denied seeing any residents left in soiled or unchanged clothing for extended periods.
During an observation on 10/9/25, visiting LPAs tested a resident’s call button and staff responded within about five minutes, indicating timely care response.
Based on the gathered information, this allegation is determined to be UNSUBSTANTIATED.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20241216143525

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: 10/17/2025

NARRATIVE

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Allegation - staff did not meet resident’s dietary needs resulting in weight loss: The investigation into this allegation consisted of record reviews and interviews.
According to weight records, R1’s weight changed over the year. On 1/8/2024, R1 weighed 128.8 pounds. Between February 5 and July 7, 2024, R1 experienced a significant weight loss of 15.6 pounds, dropping from 131.2 to 115.6 pounds. However, by 12/6/2024, R1’s weight increased to 133.2 pounds.
R1 was admitted to hospice on 7/20/2024, with a terminal diagnosis of Alzheimer’s disease and secondary diagnosis of weight loss. Hospice records indicate that R1 had decreased functional ability, minimal food intake, and refused further hospital care. Hospice care notes from August to December 2024 show that R1 received regular visits from a home health aide at least three times a week, with no issues noted related to food intake. Hospice also trained facility staff on key topics such as nutrition, hydration, and incontinent care.
A review of R1’s dietary orders confirmed that R1 was on a regular diet with no pork. The facility’s menus from April to October 2025 showed a rotating schedule of different meals for breakfast, lunch, and dinner, along with snacks between meals. The food options varied daily and included alternative meal choices.
Staff interviews revealed that R1 was given Ensure supplements with lunch and dinner, and when R1 refused a meal or disliked a dish, alternate options were offered.
R1’s assessment records show a progressive decline in abilities. In November 2023, R1 required minimal assistance with daily activities. By August 2024, R1 required full assistance with most activities, including bathing, dressing, toileting, and feeding. Staff documented that R1 often refused meals, medications, and hygiene care.
Resident interviews did not support the allegation. Residents stated that they liked the food served, received help from staff, and did not observe any issues related to staff neglecting dietary needs. While some residents expressed they wished for more staff, they confirmed their care needs were met.
Staff interviews consistently stated that dietary needs are addressed, and that staff are trained on residents’ food preferences. S4 confirmed that the kitchen maintains a list of special diets. Staff reported that residents, including R1, are checked regularly and receive assistance with meals as needed. S1 and S2 stated that R1 was assisted during meals and that R1’s food refusals and weight changes were likely due to medical condition, not from a lack of care.
Based on gathered information, the allegation is determined to be UNSUBSTANTIATED.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20241216143525

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: 10/17/2025

NARRATIVE

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Allegation - Staff consumed resident’s personal food items: The investigation into this allegation consisted of record reviews and interviews.

LPA spoke with other residents in care. Residents stated that they liked the food served and did not witnessed staff take their food. One resident stated they heard rumors about staff taking items, but denied seeing it happen. None of them reported that their own food or belongings were taken. Residents interviewed also stated staff helped them when needed, though they wished there were more staff at times.

Interviews with staff showed they all denied taking any resident’s food. They said that residents are checked regularly and helped with eating, hygiene, and changing clothes. Staff interviewed stated they did not see or hear of anyone eating food that belonged to residents.

Review of the following records, hospice care notes and facility staff care notes, do not indicate that R1’s food items were missing. During facility visits on 10/9/25, 9/17/25, and 7/21/25, visiting LPAs did not note any staff consuming residents’ food items.

Based on all the information collected, including interviews, documents, and observations, there is not enough evidence to prove that staff took or ate R1’s personal food items. Therefore, the allegation is UNSUBSTANTIATED.

Note: A finding that is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was conducted with AD and a copy of this report and appeal rights were provided.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025

LIC9099 (FAS) - (06/04)

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