342701107-11-14-2024-27-AS-AVIA-DB228V-20241114161058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701107
Report Date: 11/14/2024
Date Signed: 11/14/2024 04:11:09 PM

Document Has Been Signed on 11/14/2024 04:11 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 PLACE		FACILITY NUMBER:	342701107
ADMINISTRATOR/ DIRECTOR:	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:	11/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Damion Anderson		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/14/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Executive Director, Damion Anderson (ED) and explained the purpose of the visit. ED holds Administrator Certification # 6055657740 and expired on 3/25/2024. Per ED, he has submitted the required documents for renewal and it currently on a pending status. The facility is licensed to serve 61 non-ambulatory residents, of which 10 may be bedridden. Hospice waiver approved for 10. LPA and ED inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room were toured. Medication room was toured. Kitchen was toured for adequate food supplies and storage. A review of the facility perimeter fence, side gates, and exits was conducted. A review of the resident rooms and bathrooms were conducted. LPA observed the facility to be free of odor, clean and in good repair at this time. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Refrigerators and freezers were observed to store adequate amount of food. Temperatures for refrigerators and freezers were observed to be within regulatory standard as per observation and review of temperature log. The hot water temperature was measured at 118 degrees Fahrenheit in 4 sample resident rooms. The room temperature inside the facility measured between 71 and 75 degrees Fahrenheit. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to residents. LPA observed the fire extinguisher(s) were up to date and were last serviced on 6/7/24. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. First aid kit was checked and is complete. Report continued on 809-C

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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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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: 11/14/2024

NARRATIVE

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Review of 8 sample resident files (R1 - R8) include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Issues were noted: R5 did not have updated Physician's Report for review during this visit. Last Physician's Report on file was on 7/21/20. Per interview with ED confirmed they do not have the document on file for review but informed they sent the form to R5's physician.

Medication review of 2 sample residents (R1 and R2) include review of physician orders for over-the-counter medications. No issues were noted at this time.

Review of 6 sample staff files (S1 - S3) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. No issues were noted at this time.

Facility conducts quarterly disaster/evacuation drill and last drill was on 10/2/24. Facility has a dementia care plan and infection control plan.

The following documents were obtained during today's visit:
LIC 308 Designation of Administrative Responsibility, Proof of Current Liability Insurance, Resident Roster, LIC 500 Personnel Report and Staff Schedule for October 2024 and November 2024.

Per California Code of Regulations, Title 22, deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/14/2024 04:11 PM - It Cannot Be Edited

Created By: Arvin Villanueva On 11/14/2024 at 03:46 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: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia: Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review the licensee did not comply with the section cited above. R5 did not have updated Physician's Report on file for review during this visit. Last Physician Report on file was completed on 7/21/20. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/21/2024
	Plan of Correction
1 2 3 4	Per discussion with the Executive Director (ED), licensee with submit a plan to ensure all required records are complete and available for review at anytime. Plan to be submitted to the Department by POC due date. Per discussion with ED, they will submit R5's updated Physician's Report by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Richardson

LICENSING EVALUATOR NAME:

Arvin Villanueva

LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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