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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701107
Report Date: 06/27/2025
Date Signed: 06/27/2025 04:08:20 PM

Document Has Been Signed on 06/27/2025 04:08 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:REGENCY PLACEFACILITY NUMBER:
342701107
ADMINISTRATOR/
DIRECTOR:		DAMION E. ANDERSONFACILITY TYPE:
740
ADDRESS:8190 ARROYO VISTA DRIVETELEPHONE:
(916) 681-7800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 61CENSUS: 52DATE:
06/27/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Damion E AndersonTIME VISIT/
INSPECTION COMPLETED:
04:33 PM
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Licensing Program Analyst (LPA) Cynthia Tamayo conducted an unannounced case management deficiency visit at the Regency Place II on June 17, 2025 at 2:10 P.M. LPA met with Administrator Damion E Anderson and informed them of the purpose of todays visit was to follow up on the AWOL for Sally Ebersole (R1) on 6/12/2025.

An SIR was received for R1 informing R1 exited the facility unassisted (AWOL). current LIC 602 (dated 11/5/2021) indicated resident cannot leave facility unassisted. Based on record review facility was conducting hourly checks since 5/2025 for R1 due to daughter request for supporting medical verification. Hour check Log from 6/12/25 shows resident was checked on at 6:00PM at the note indicates she was in the lobby. The Med-Tech informed the S1 that R1 stated "I am going to my room". Security Camera's show resident exited the back door at 6:15PM and was found around 6:30 PM. S2 stated R1 told them they where leaving the facility to visit their daughter. S1 stated R1 was moved into Memory Care on 6/13/25.

LPA toured the facility an exit door near room 27 to be propped open. S1 stated the house keeper sometimes props the door open during business hours (before 5;00PM when they are doing laundry. S1 stated they will make sure Hours keeping has a key in order to not prop doors open. S1 stated there is a sensor for the back door but there is no sensor for the door that leads to exterior as it is access for Independent Living Residents. The exit door in the dining room does not have an alarm and it locks at 7:00PM each day. There will be a new signal system put in place for exit doors. LPA Tamayo interviewed R1, and they declined leaving the facility and do not recall going out by themselves to visit their daughter. R1 is listed as Mild Cognitive Impairment (MCI). Administrator is requested updated LIC 602 and is pending Kaiser Physician appointment.

Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: REGENCY PLACE
FACILITY NUMBER: 342701107
VISIT DATE: 06/27/2025
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LPA Tamayo reviewed Staff Roster, Staff Schedules, Resident File (R1). LPAs reviewed the Physicians Report for R1 which indicates R1 is unable to leave the facility unassisted. R1 does not have a history of elopement. Facility has conducted elopement training and has a prepared elopement bag. Additional alarms are being put in place by 7/27/2025.

Based on interviews and records review, it was determined that R1 eloped from the facility without staff knowledge. R1's Physician Report (LIC 602) states that resident was not allowed to leave the facility unassisted. Facility staff shall have supervision of R1 and aware of R1’s general whereabouts at all times. Re-appraisal will be completed for R1.

Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. An immediate civil penalty of $500.00 is assessed for health and safety deficiency.

Exit interview conducted, a copy of the report, 809-D and appeal rights given.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2025 04:08 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 06/27/2025 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: REGENCY PLACE
FACILITY NUMBER: 342701107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2025
Section Cited
HSC
1569.312(d)

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1569.312 Basic services requirements (d)) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidence by:
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Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. A statement of correction will be submitted by plan of correction date via email to LPA Tamayo. Facilty has relocated R1 to memory care to ensure their safety from elopment.
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Based on incident report, the facility did not comply with section cited above. R1 AWOL'D from facility without staff knowledge. The LIC 602 states the resident was not allowed to leave the facility unassisted. This poses an immediate health and safety risk to the resident in care.
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 Proof of staff training for the cited section will be completed and asignature sheet of all staff who attended will be submitted to LPA after training is finished.

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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
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