565850112-8-12-2026-29-AS-KHEN-DXDUYV-20260828160034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850112
Report Date: 08/12/2026
Date Signed: 08/12/2026 04:57:21 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2026 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20260506152647

FACILITY NAME:	REGENCY PALMS OXNARD		FACILITY NUMBER:	565850112
ADMINISTRATOR:	STEPHANI SMITH		FACILITY TYPE:	740
ADDRESS:	1020 BISMARK WAY		TELEPHONE:	(805) 247-0227
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	127	CENSUS: 93	DATE:	08/12/2026
		UNANNOUNCED	TIME BEGAN:	10:23 AM
MET WITH:	Ty Hanson, Sales Director		TIME COMPLETED:	05:05 PM

ALLEGATION(S):

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Staff do not ensure that residents’ colostomy bag care is being properly maintained

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit regarding the above noted allegation. Upon arrival, LPA was greeted by front desk staff. LPA then met with Sales Director Ty Hanson. Entrance interview conducted.

During today’s visit, LPA interviewed five (5) staff and one (1) family member from 10:37AM to 11:45AM, and from 12:44PM to 03:54PM. LPA conducted a tour of the facility with Sales Director at 12:16PM. During an initial visit conducted on 05/13/2026, LPA conducted interviews with four (4) staff from 10:44AM to 04:35PM, toured the facility with staff at 04:40PM, and LPA reviewed and obtained copies of documents relevant to the investigation. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted additional interviews with staff and other relevant parties. The following was then determined:

Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260506152647

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: REGENCY PALMS OXNARD	FACILITY NUMBER: 565850112
	VISIT DATE: 08/12/2026

NARRATIVE

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The complaint alleges that Resident #1 (R1)’s colostomy care needs are not being met. Interview with staff revealed that at the time of the complaint, care staff had not been trained on colostomy care. Since the care staff had not been trained on emptying the bag, they were not assisting R1 in emptying their colostomy bag. Staff indicated that R1, who resides in the memory care unit, can at times empty their own colostomy bag, but is not consistently able to do so. When R1’s colostomy bag would get full, staff would inform R1’s home health provider and if the nurse was available, she would come out to change the bag. Previously, there had been a home health nurse visiting daily, however at the time of the complaint, home health was regularly able to visit three (3) times a week. No home health care plan was available to review for R1. Staff also indicated that if needed, R1’s family member can change R1's colostomy bag if the home health provider was not available, but there were times when neither the family member nor home health were available to change the bag and the facility staff had to seek emergency medical treatment for R1. Record review revealed R1 had been seen at the hospital and was discharged on 10/09/2025 with colostomy care instructions. This document states “empty your bag at bedtime…and whenever it is one-third to one-half full. Do not let the bag get more than half-full with stool or gas.” Interview revealed R1’s home health provider is not visiting the facility to empty R1’s colostomy bag before bedtime, as ordered. Instead, home health would come to the facility when requested, as the home health nurse’s availability allowed. Staff interviewed stated the staff did not empty R1’s colostomy bag before bedtime, as they had not been trained. Interview with staff and witness revealed that R1’s colostomy bag was not emptied regularly, but was changed by the home health nurse when it was observed to be well over half-full, when R1 would begin picking at it, or when it had been dislodged from the stoma site. Based on observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See LIC 9099-D).

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

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20260506152647

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: REGENCY PALMS OXNARD	FACILITY NUMBER: 565850112
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/26/2026 Section Cited CCR 87621(b)(1)	1 2 3 4 5 6 7	87621 Colostomy/Ileostomy (b) In addition to Section 87611(b), the licensees shall be responsible for the following: (1) Ensuring that ostomy care is provided by an appropriately skilled professional. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility conducted a colostomy training with a medical professional on 07/03/2026. Designee will send a statement indicating a tentative schedule for ongoing staff training. Additionally, designee will obtain and send a copy of a complete home health plan for R1 to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the above cited section, as R1 was admitted to the facility with a colostomy, no home health care plan addressing colostomy care, nor staff training related to colostomy care, which posed a potential health & personal rights risk to R1.	8 9 10 11 12 13 14
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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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

LIC9099 (FAS) - (06/04)

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