<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850112
Report Date: 01/22/2024
Date Signed: 01/22/2024 05:22:30 PM


Document Has Been Signed on 01/22/2024 05:22 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:REGENCY PALMS OXNARDFACILITY NUMBER:
565850112
ADMINISTRATOR:KENNETH MAHLERFACILITY TYPE:
740
ADDRESS:1020 BISMARK WAYTELEPHONE:
(805) 247-0227
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:127CENSUS: 79DATE:
01/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Kenneth MahlerTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 11:00 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 01/04/2024. The LPA was greeted by Administrator Ken Mahler and informed them of the reason for the visit.

Today the LPA conducted a medication audit and finished the record review initiated on 1/04/2024.

Record Review: At 11:15 a.m. the LPA observed documentation of Infection Control Plan, Disaster prevention and last fire drill (conducted on 12/19/2023). The LPA obtained Resident and Staff Rosters. The LPA reviewed one (1) out of seventy-nine (79) resident files, the file appeared complete and current. The LPA observed five (5) out of fifty-six (56) staff files which included but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid certification. Out of the five files reviewed, three out of five staff (S1, S3, S4) require first aid certification, In addition, the LPA was unable to identify the completed eight (8) hours of annual medication training nor could the LPA identify annual training for restricted health conditions for two out of the five staff (S1,S2).

Medications: At 3:00 p.m. a medication review was initiated for two out of five residents and the following was observed. The medications were stored in medication rooms, which are locked and inaccessible to the residents. During Resident #1 (R#1's) audit, the LPA observed Telmisartan 40MG and Memantine HCL 10MG documented on the Medication Administration Record (MAR) as given on 1/7/24, however the medications were still in the bubble packs.
During R#2’s audit, the LPA observed four (4) medications not documented on the Centrally Stored Medication and Destruction Record (CSMDR).

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Ken Mahler.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


Document Has Been Signed on 01/22/2024 05:22 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: REGENCY PALMS OXNARD
FACILITY NUMBER: 565850112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as one out of five residents did not get their medication as prescribed which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/25/2024
Plan of Correction
1
2
3
4
Administrator agreed to conduct medication training for all MedTechs and subit to LPA by no later than end of day 1/25/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 01/22/2024 05:22 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: REGENCY PALMS OXNARD
FACILITY NUMBER: 565850112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in three out of five staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
1
2
3
4
The Administrator has agreed to the following:
1. Submit the completed first aid certification for all three staff by POC due date.
Request Denied
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two out of five staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
1
2
3
4
The Administrator has agreed to the following:
1. Conduct restricted health conditon training for S1 and S2 and submit proof to LPA by 2/2/24.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 01/22/2024 05:22 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: REGENCY PALMS OXNARD
FACILITY NUMBER: 565850112

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two out of five staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2024
Plan of Correction
1
2
3
4
The Administrator has agreed to the following:
1. Conduct 8 hrs of medication training for S1 and S2 and submit proof to LPA by 2/2/24.
Type B
Section Cited
CCR
87465(h)(6)(A-F)
The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as four medications were not documented on the centrally stored medication and destruction record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
1
2
3
4
Administrator has agreed to conduct a medication records audit for MC and submit a self-certification letter to LPA by no latern than 2/2/24.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6