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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701107
Report Date: 10/24/2023
Date Signed: 10/24/2023 04:01:22 PM


Document Has Been Signed on 10/24/2023 04:01 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:REGENCY PLACEFACILITY NUMBER:
342701107
ADMINISTRATOR:DAMION E. ANDERSONFACILITY TYPE:
740
ADDRESS:8190 ARROYO VISTA DRIVETELEPHONE:
(916) 681-7800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:61CENSUS: 46DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Damion AndersonTIME COMPLETED:
04:20 PM
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On 10/24/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection. LPA met with Administrator Damion Anderson and explained the purpose of the visit.

Administrator holds certification # 6055657740 and expires on 3/25/2024. The facility is licensed to serve 61 non-ambulatory residents, of which 10 may be bedridden. Hospice waiver approved for 10. There are 46 residents in care currently.

LPA toured and 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 was 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 was conducted.

LPA observed the facility to be free of odor, clean and in good repair. 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. The hot water temperature was measured at 119.1 degrees Fahrenheit. The temperature inside the facility measured at 74.0 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. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. First aid kit was checked and is complete. Proof of current liability insurance was observed.

Report continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/24/2023
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LPA requested resident and staff files for review. LPA reviewed six (6) resident files and five (5) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents were obtained during today's visit:
LIC 308 Designation of Administrative Responsibility, Administrator Certificate, and Proof of Current Liability Insurance, LIC 500 Personnel Report and LIC 610 Emergency Disaster Plan.

Per California Code of Regulations, Title 22, no deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2