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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802408
Report Date: 07/05/2024
Date Signed: 07/05/2024 01:30:45 PM


Document Has Been Signed on 07/05/2024 01:30 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:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Donald Brodt - AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. The Administrator, Donald Brodt arrived shortly after.

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

The LPA inspected the kitchen/food service area at approx. 9:00 a.m. The LPA observed one resident watching television. Knives are stored in a locked drawer to the left of the stove.  Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time.

At the time of the visit, the living room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguisher to be fully charged and purchased this year.

The LPA observed four (4)  resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The  resident restrooms were 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 in each restroom between 105 - 120 degrees Fahrenheit.  The staff area  was observed to be inaccessible to residents in care and empty during the time of the visit. Room #1 is not part of the facility and is rented out to a tenant who does not receive any care or supervision from staff. LPA observed room to be inaccessible to residents in care at this time.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
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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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: 07/05/2024
NARRATIVE
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There is an Office area / employee lounge. LPA observed extra supply of non-perishable goods, medical supplies, emergency food, and other facility supplies.  All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space.  The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted at the time of the visit. There is a storage shed located in the rear of the facility. LPA observed it to store extra facility and medical supplies at this time.

Records review began at 10:00am. Five (5) resident records were reviewed for the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, appraisals, and current needs and services plan. All resident records were observed to be in order at this time.

LPA reviewed staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification.

At approx 11am, LPA observed Staff #1 (S1) to have criminal background clearance, but they were not associated to this facility. Administrator's file was not available to review at the time of the visit. Staff training records were not available to review at the time of the visit.  Last emergency disaster drill conducted last quarter. Administrator will conduct drill by end of month.

Medications review began at 11:05 a.m. The medications are centrally stored and locked in a cabinet in the office area. Medications are labeled and checked for expiration dates. No errors found during medication audit.

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 promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
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: 07/05/2024
NARRATIVE
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Continued from 809-C

LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. Interviews were conducted during the visit.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $500. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/05/2024 01:30 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: 07/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 S1 did not have their clearance transferred to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2024
Plan of Correction
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Licensee agreed to submit a transfer of a criminal record clearance for all staff not associated to the facility by 07/08/2024. Licensee will submit proof of clearance to LPA via email by eod 07/08/2024.
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: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 07/05/2024 01:30 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: 07/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)
Adminstrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

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 the Administrator file did not have file to review on site, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee agreed to maintain full Administrator file in the facility. Licensee also agreed to submit proof of understanding and submit to LPA via email by EOD 07/12/2024
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 staff training files were not kept current, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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Licensee agreed to maintain full updated staff trainining file in the facility. Licensee also agreed to submit proof of understanding and submit to LPA via email by EOD 07/12/2024
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: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5