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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701107
Report Date: 06/02/2026
Date Signed: 06/02/2026 03:46:38 PM

Document Has Been Signed on 06/02/2026 03:46 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:		HEIDI CHARETTEFACILITY TYPE:
740
ADDRESS:8190 ARROYO VISTA DRIVETELEPHONE:
(916) 681-7800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 61CENSUS: 77DATE:
06/02/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Executive Director: Martin NicholsTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 06/02/2026 Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to conduct a case management regarding an AWOL incident report received by the Dept on 06/01/2026. LPA met with the facility Administrator/ Executive Director Martin Nichols and explained the purpose of the visit. The census is 77 with 14 facility staff present.

LPA Hughes interviewed the facility administrator and reviewed the incident report dated 05/28/2026. Based on interview and review of the incident report R1 exited the memory care unit and was later found near the facility's trash area on the opposite side of the property. R1 was returned to the memory care unit by the facility housekeeper after being observed outside of the designated secured area on 05/28/2026.

R1's LIC 602 Physician's Report dated 01/28/2025 was reviewed by LPA Hughes which revealed that (R1) is unable to leave the facility unassisted.

Based on today's case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is issued in addition to citation due to absence of supervision. An exit interview was conducted with the facility Administrator/ Executive Director Martin. A copy of this report LIC 809, LIC 809-D, LIC 421IM and Appeal rights was provided at the end of the visit.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Shakaricka Hughes
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2026
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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Document Has Been Signed on 06/02/2026 03:46 PM - It Cannot Be Edited


Created By: Shakaricka Hughes On 06/02/2026 at 03:02 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: 06/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2026
Section Cited
CCR
87464(f)(1)

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87464(f)(1) Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
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The facility will ensure compliance with Title 22 regulation 87464 at all times. The facility will conduct in-service training with all facility staff working in the memory care unit on care and supervision, and resident elopement. The facility will send LPA proof of training by 06/05/2026 via email at shakaricka.hughes@dss.ca.gov
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This requirement was not met as evidenced by:
The facility did not ensure that a resident in care (R1) was adequately supervised from wandering away from the designated memory care unit and was found near the facility's trash can. This poses in immediate health and safety risk to residents in care.
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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:
Shakaricka Hughes
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2026


LIC809 (FAS) - (06/04)
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