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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005940
Report Date: 07/14/2021
Date Signed: 07/14/2021 10:59:25 AM

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:
347005940
ADMINISTRATOR:HARUMI HURRIANKOFACILITY TYPE:
740
ADDRESS:8190 ARROYO VISTA DRTELEPHONE:
(916) 681-7800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:55CENSUS: 51DATE:
07/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Elizabeth CruzTIME COMPLETED:
11:00 AM
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On 07/14/21 at 8:45 AM , LPA Suong Teh and Eimile Nolan arrived at this facility unannounced to conduct an annual inspection visit. LPA was greeted by the facility administrator Elizabeth Cruz. LPA was screened upon entry for COVID precautions. Elizabeth accompanied LPA on facility tour

LPA Teh inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 55 bed facility with a current census of 51. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications were noted to not be accessible to residents in care. LPA also conducted the infection control domain tool.
The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: REGENCY PLACE
FACILITY NUMBER: 347005940
VISIT DATE: 07/14/2021
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Water temperature reads 105 F and the facility temperature registered at 73 F. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Total od nine (9) Fire extinguisher were checked April 2021. Facility has an emergency food and water supply in a separate storage area in kitchen. LPA requested the following documents to be updated: LIC 610E, and LIC 308.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Elizabeth Cruz.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC809 (FAS) - (06/04)
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