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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701107
Report Date: 01/23/2023
Date Signed: 02/22/2023 10:58:15 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2022 and conducted by Evaluator Jamie Ivey-Canady
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221014152649
FACILITY NAME:REGENCY PLACEFACILITY NUMBER:
342701107
ADMINISTRATOR:CRUZ, ELIZABETHFACILITY TYPE:
740
ADDRESS:8190 ARROYO VISTA DRIVETELEPHONE:
(916) 681-7800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:61CENSUS: 45DATE:
01/23/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elizabeth CruzTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility did not notify resident's responsible party of an incident in a timely manner.
Resident sustained a fracture while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)s Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Elizabeth Cruz.
 
The investigation was conducted by the Department. The investigation consisted of interviews with staff, review of resident medical reports, facility chart notes and facility resident files.

The Department has determined the following as it relates to the allegations: Resident sustained a fracture while in care and Facility did not notify resident's responsible party of an incident in a timely manner.


Continued on LIC 9099 - C...
Page 1 of 2

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
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-20221014152649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 342701107
VISIT DATE: 01/23/2023
NARRATIVE
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On 1/05/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady interviewed facility staff regarding the current allegations. Staff 1 (S1) Stated Resident 1 (R1) had incurred a fall at approximately 2 am in the morning on 09/17/2022. R1 was discovered on the floor and assisted back into the bed. According to interview with S1, R1 was attempting to go to the rest room. On 1/17/2023 LPA reviewed documentation sent to R1's physician from the facility. The documentation was a notification that R1 had fallen but had no pain. According to S2, there are no call buttons located in the rooms where R1 was located which was memory care. S2 stated the emergency call button is in the bathrooms. According to interview with S1, and S2, R1 family was contacted approximately 16 hours later, on 9/17/2022 at approximately 2pm because R1 stated there was pain, at which point the family provided the directive to transfer the resident to a medical facility. In regard to Title 22 Regulations, 16 hours is a significant amount of time that the family was not contacted regarding R1 fall and subsequent possible injuries. Therefore, the allegation Facility did not notify resident's responsible party of an incident in a timely manner is substantiated. Based on the Department document reviews including medical file, along with Staff and witness interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

On 1/05/2023 and 1/17/2023 LPA Ivey Canady completed documentation review of materials submitted to the Regional Office by the department. According to medical documentation review, R1 sustained a displaced intertrochanteric fracture of the left femur. According to medical documentation the cause of the injury was an unwitnessed fall that occurred at the facility on 9/17/2022. Based on further review of medical documentation a fracture of the right rib was also discovered from the hospital’s x-ray. The Department noted the right rib fracture was present in medical documentation prior to R1 being admitted to the facility. However, based on medical documentation, the fracture to the left femur occurred at the facility on 9/17/2022. Therefore, the allegation Resident sustained a fracture while in care is SUBSTANTIATED. Based on the Department document reviews and LPA medical file reviews along with Staff and witness interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Page 2 of 3
Cont on 9099-C
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20221014152649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 342701107
VISIT DATE: 01/23/2023
NARRATIVE
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This entry has been deleted due to approved amendment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20221014152649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 342701107
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2023
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall...(8)To have their representatives regularly informed by the licensee of activities related to care... This requirement was not met as evidenced by:
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Licensee/administrator stated training will be provided to staff regarding contacting responsible party's in a timely manner. Administrator will provide documentation of training within 24 hours via email to LPA.
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Based on interviews and record review, The licensee did not ensure a resident’s family was notified of resident fall timely which poses a potential danger to the health and safety risk of residents in care
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Type A
01/23/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities...(4) To care, supervision, and services that meet their individual needs and are delivered by staff...This requirement was not met as evidenced by:
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Licensee/administrator stated training will be provided to staff regarding ensuring residents receive assistance with ambulating in memory care. Administrator will provide documentation of training within 24 hours via email to LPA.
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Based on interviews and record review, The licensee did not ensure a resident had the appropriate measures to receive assistance when attempting to ambulate from a laying position which poses an immediate health and safety risk of 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20221014152649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 342701107
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2023
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f) Basic services shall at a minimum...(4)Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal...This was not met as evidenced by:
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Licensee/administrator stated training will be provided to staff regarding ensuring pre-appraisals are in alignment with services facility is providing. Administrator will provide documentation of training within 24 hours via email to LPA.
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Based on interviews and record review, The licensee did not ensure services from the facility were provided to a resident as pertained to resident pre-appraisal conducted by the facility which poses an immediate health and safety risk of 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5