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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701107
Report Date: 05/02/2024
Date Signed: 05/02/2024 10:20:11 AM


Document Has Been Signed on 05/02/2024 10:20 AM - 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:DAMION E. ANDERSONFACILITY TYPE:
740
ADDRESS:8190 ARROYO VISTA DRIVETELEPHONE:
(916) 681-7800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:61CENSUS: 72DATE:
05/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Damion AndersonTIME COMPLETED:
10:45 AM
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On 5/2/24, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit regarding an incident report the Department received on 4/12/24. LPA met with Administrator Damion Anderson and explained the purpose of the visit.

The purpose of this case management visit is to follow up on an incident that was occurred on 4/11/24. Per incident report, staff (S1) was in the activity room providing supervision over the resident. S1 noticed smokes coming from the kitchen stove top. S1 turned off the electric stove and removed a food serving tray from the stovetop to the sink to attempt to put out the fire. Staff (S2) grabbed a fire extinguisher form the front lobby and began extinguishing fire.

During today’s visit, LPA Truong toured the facility and interviewed staff. It was learned that staff (S3) might have accidentally turned on the stove when setting the food tray on the stove. The plastic food tray was melted causing a small fire. It was learned that staff was present during the incident and no residents were harmed. The fire only causing damage to the food tray.

Administrator was advised that additional interviews are needed in order to make a determination.

No deficiencies were observed during today’s visit pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
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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