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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601685
Report Date: 05/03/2024
Date Signed: 05/03/2024 02:08:24 PM


Document Has Been Signed on 05/03/2024 02:08 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:REGENCY FALLBROOKFACILITY NUMBER:
374601685
ADMINISTRATOR:KARI MORENOFACILITY TYPE:
740
ADDRESS:609 E.ELDER STREETTELEPHONE:
(760) 728-8504
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:75CENSUS: 55DATE:
05/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:ADMINISTRATOR, KARI MORENOTIME COMPLETED:
02:11 PM
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On May 03, 2024, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced case management with deficiencies visit and met with the Administrator. An Unusual Incident(SIR) was received for the facility on 05/01/2024, that stated a staff intimidated a resident in care. Deficiencies will be cited.

LPA Mixson introduced herself, stated the purpose of the visit, and toured the facility along with the Administrator. LPA made observation and requested and received pertinent documentation.

Currently at the facility are 40 staff and 55 residents there were no observable regulation violation during the tour of the facility. There were no imminent health or safety concerns observed at the time of visit. LPA Mixson observed the facility had working utilities and was clean and organized. The LPA observed adequate staffing to provide supervision for the residents in care. LPA Mixson observed the facility had more than a two-day supply of perishable foods and seven day supply of non-perishable food items. Medications were found to be in sufficient supply and were locked and inaccessible to residents.


An exit interview was conducted where a copy of this report was reviewed, explained, and provided to Administrator Kari Moreno along with the Confidential Names List (LIC811), LIC809-D and Appeal Rights.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
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 05/03/2024 02:08 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: REGENCY FALLBROOK
FACILITY NUMBER: 374601685

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
87468.1(a)(3)

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Personal Rights of Residents in All Facilities to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature…. This requirement is not met as evidence by:
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The Administrator stated that all staff will be retrained on Personal Rights, and how to communicate with the residents in care, and would proved to the Department by Friday May, 10, 2024.
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Based on information obtained from the Unusual Incident Report (SIR) received by the Department on 05/01/2024, the facility self reported, the licensee did not ensure that facility's residents to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature…. which poses an immediate health, safety, or personal rights risk to a person in care.

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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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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