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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015201935
Report Date: 01/23/2023
Date Signed: 01/23/2023 12:46:36 PM


Document Has Been Signed on 01/23/2023 12:46 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:REGENT HOMEFACILITY NUMBER:
015201935
ADMINISTRATOR:SANGCO, KAREN L.FACILITY TYPE:
734
ADDRESS:2508 REGENT ROADTELEPHONE:
(925) 371-5274
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:5CENSUS: 5DATE:
01/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Karen Sangco, AdministratorTIME COMPLETED:
12:58 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
On 1/23/2023 at 10:30AM, Licensing Program Analysts (LPAs) G. Luk and C. Fowler arrived unannounced to conduct a case management visit in regards to incident report received on 1/14/2023. LPAs met with Administrator, Karen Sangco.

Incident report dated 1/13/2023 revealed that C1 fell from the shower gurney on 1/13/2023 as a result of unlatched side rail. 911 was called and C1 was taken to hospital on the same day.

During visit, LPA obtained and reviewed hospital discharge documents, facility notes (1/13/2023 - 1/23/2023), and x-ray reports.

In facility notes, ER doctor informed facility that C1 sustained right distal femur fracture. Awaiting Ortho recommendations. X-rays showed that C1 had a displaced oblique distal femur fracture.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
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 2


Document Has Been Signed on 01/23/2023 12:46 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: REGENT HOME
FACILITY NUMBER: 015201935

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2023
Section Cited

1
2
3
4
5
6
7
Personal Rights.
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator has agreed to create a written plan for all staff training & teach back regarding shower & transfer/repositioning procedures. Administrator will submit written plan to CCLD by POC date.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above by not having shower gurney side rail up which poses an immediate health and safety risk to the clients in care.
8
9
10
11
12
13
14
Training will be completed within a week.

Civil penalty of $500 is being assessed.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2