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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802408
Report Date: 07/21/2023
Date Signed: 07/21/2023 02:26:40 PM


Document Has Been Signed on 07/21/2023 02:26 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:REGAL CAREFACILITY NUMBER:
565802408
ADMINISTRATOR:BRODT, DONALDFACILITY TYPE:
740
ADDRESS:3316 GREENVILLE AVENUETELEPHONE:
(805) 587-2992
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 5DATE:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Donald BrodtTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. Upon arrival, the LPA was greeted by staff. The Administrator, Donald Brodt arrived shortly after and the reason for the visit was explained. Entrance interview conducted.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 10:00 a.m. Knives are stored in a drawer next to the oven inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Water temperature was measured in the kitchen sink at it measured at 112.1 degrees Fahrenheit at 10:03 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature of 75 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguishers were fully charged and purchased on 07/10/2023. The LPA observed required postings throughout the common space. The last earthquake drill took place on 07/07/2023. Activities were observed in the common areas. Fireplace was observed adequately screened. The LPA observed an adequate supply of emergency food and water. The laundry room is locked and inaccessible. Cleaning supplies and toxins were observed in the laundry room locked and inaccessible.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: REGAL CARE
FACILITY NUMBER: 565802408
VISIT DATE: 07/21/2023
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Report Continued from LIC 809C...

RESTROOMS: The resident restroom appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured at110.6 degrees Fahrenheit at 10:19 a.m.

At 10:16 a.m., the LPA observed several items in the shower. Items observed unlocked and accessible to resident included: shampoo, conditioner, and body wash. Upon review of R1’s Physician’s Report (LIC 602A) dated 02/23/2023, R1 is at risk if allowed direct access to personal grooming and hygiene items. These items were locked away inaccessible to residents at the time of visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting.

At 10:20 a.m., LPA observed medications and body cleansers in Room #5 accessible to residents in care. Items were immediately locked in the medication’s cabinet.

RECORDS: LPA reviewed Resident Records at 10:34 a.m. and Personnel Records at 11:16 a.m.

Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order.

Two (2) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

MEDICATIONS: Medications review began at 1:55 p.m. The medications are locked in a cabinet inside the office. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: REGAL CARE
FACILITY NUMBER: 565802408
VISIT DATE: 07/21/2023
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Report Continued from LIC 809C...

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promote good hand hygiene. The facility has an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/21/2023 02:26 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: REGAL CARE
FACILITY NUMBER: 565802408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615(a)(5)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as R2 has no capacity for self-care and is not on hospice, nor does the facility have an exception on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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The Licensee locked items at the time of visit.
The Licensee will review Regulation 87615 and submit statement of understanding to CCL by 07/31/2023.
Type A
Section Cited
CCR
87705(g)
Care of Persons with Dementia
(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as items such as shampoo, conditioner, body wash, and medication was accesible to resident in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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The Licensee will review Regulation 87705 and submit statement of understanding to CCL by 07/31/2023.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 07/21/2023 02:26 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: REGAL CARE
FACILITY NUMBER: 565802408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Observation, the licensee did not comply with the section cited above as R2's last Physician's Report was condcuted in 2020, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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The Licensee has agreed to have Physician's Report updated for R2 and submit proof to CCL by 07/31/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5