191200037-6-2-2023-28-AS-MGFS-CSEUG5-20230602153345

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191200037
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:33:52 PM

Document Has Been Signed on 06/02/2023 03:33 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	REGENCY PARK OAK KNOLL		FACILITY NUMBER:	191200037
ADMINISTRATOR:	ANABELLE ARGENAL		FACILITY TYPE:	740
ADDRESS:	255 SOUTH OAK KNOLL		TELEPHONE:	(626) 578-1551
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY:	206	CENSUS: 79	DATE:	06/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:07 AM
MET WITH:	Jacqueline Hernandez - Business Manager		TIME COMPLETED:	03:45 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	Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Jacqueline Hernandez Business Manager and explained the reason for the visit. Administrator Anabelle Argenal arrived 45 minutes later. The facility is licensed to serve 206 ambulatory and non-ambulatory (in rooms 101-140, except 110, and rooms 201-267) residents over the age of 60, with a hospice waiver for 10. The facility is a two story building located in a residential area and consist of a commercial kitchen, a lobby sitting room area, a dining room, a living room area, a beauty salon, a coffee parlor, an activity room, and a patio. The second floor has a conference room, a patio and most resident rooms. Facility serves dementia residents. LPA conducted a tour of the facility with Jacqueline Hernandez and observed the following: Facility is clean and in good repair indoors and outdoors. Commercial kitchen was observed clean and walking refrigerator and freezer have sufficient food for at least 2 days of perishables and 7 days of non-perishables. Emergency food supplies were observed in a separate closet. 7 resident bedrooms (#105, 107,118,244,265,209,232), were observed to have sufficient lighting, and the required furniture/bedding supplies. Half bed rails were observed in bedrooms #118 and #232. Water temperature was tested in each resident's bathroom; tested between 110.8 and 119.7 degrees F. which is within the required 105-120 degrees F. Activity room was observed with sufficient activity supplies. Patio is enclosed with sufficient shaded sitting area and water features are enclosed by a fence. Facility has a fire sprinkler system throughout. Fire extinguishers were observed and last checked on 7/7/22. Each emergency exit was tested and are in working condition. Call button system in room #232 was tested and staff responded within less than 5 minutes. Last fire drill was conducted on 3/30/23. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY PARK OAK KNOLL	FACILITY NUMBER: 191200037
	VISIT DATE: 06/02/2023

NARRATIVE

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LPA reviewed medication and files for 5 residents and 5 staff files. Resident file review revealed resident #1(R1)'s last physician's report is dated 12/1/21, #2(R2)'s last physician report is dated 4/14/22 and resident #5(R5)'s last physician report is dated 4/20/22. No physician's request for half bed rails for R2 and R5 were observed.

Administrator certificate was observed for Anabelle Argenal #6034626740 exp. date: 4/21/23, renewal documentation has been received by the department.

A copy of liability insurance was requested. LPA interviewed 4 staff and 4 residents.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Anabelle Argenal Administrator and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 06/02/2023 03:33 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY PARK OAK KNOLL	FACILITY NUMBER: 191200037
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in resident #1,#2, and #5 do not have a current medical assessesment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/16/2023
	Plan of Correction
1 2 3 4	Administrator will obtain annual medical assessment for R1, R2, and R5 and will submit a copy to the department by POC due date 6/16/23.

Type B

Section Cited

CCR

87608(a)(5)(A)

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in resident #2 and #5 beds were observed with half bed rails and a physician's request was not on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/16/2023
	Plan of Correction
1 2 3 4	Administrator will request physician's order and will submit a copy to the department by POC due date 6/16/23.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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