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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701107
Report Date: 08/23/2024
Date Signed: 08/23/2024 12:06:24 PM


Document Has Been Signed on 08/23/2024 12:06 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:DAMION E. ANDERSONFACILITY TYPE:
740
ADDRESS:8190 ARROYO VISTA DRIVETELEPHONE:
(916) 681-7800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:61CENSUS: 51DATE:
08/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Damion AndersonTIME COMPLETED:
10:30 AM
NARRATIVE
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On 8/23/24, 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 8/16/24. 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 occurred on 8/12/24. Resident (R1) is a 102-year-old resident with dementia who eloped from the facility on 8/12/2024. R1 was last seen at 12:50 PM and was found outside of the community’s grounds at 1:15 PM by facility staff returning from lunch.

Based on interviews and records review, it was determined that R1 eloped from the facility without staff knowledge. R1's Physician Report (LIC 602) states that resident was not allowed to leave the facility unassisted. Facility staff shall have supervision of R1 and aware of R1’s general whereabouts at all times.

Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. An immediate civil penalty of $500.00 is assessed for health and safety deficiency.

Exit interview conducted, a copy of the report, 809-D and appeal rights given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
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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Document Has Been Signed on 08/23/2024 12:06 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2024
Section Cited
HSC
1569.312(d)

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Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services:...(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidence by:
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Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. A statement of correction will be submitted by plan of correction date of 8/26/2024 via email to LPA Tung Truong. Proof of staff training for the cited section will be completed and asignature sheet of all staff who attended will be submitted to LPA after training is finished.
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Based on incident report, the facility did not comply with section cited above. R1 AWOL'D from facility without staff knowledge. The LIC 602 states the resident was not allowed to leave the facility unassisted. This poses an immediate health and safety risk to the resident in care.
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Immediate civil penalty of $500.00 is assessed for health and safety deficiency.

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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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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