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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881303
Report Date: 11/04/2024
Date Signed: 11/04/2024 01:37:04 PM

Document Has Been Signed on 11/04/2024 01:37 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:REGENCY RANCH CARE HOMEFACILITY NUMBER:
331881303
ADMINISTRATOR/
DIRECTOR:		CALMA, MARICELFACILITY TYPE:
740
ADDRESS:16005 REGENCY RANCH RDTELEPHONE:
(951) 776-3289
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 6CENSUS: 2DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Maricel CalmaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with administrator, Maricel Calma. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

LPA toured the facility inside and outside. LPA observed the facility to be clean. The facility consists of four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. The home is maintained at a comfortable temperature for the clients. LPA observed lighting in the master bathroom having multiple lights non operational. A citation will be issued to correct to meet sufficient lighting in the area. Water temperature measured 108.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home. LPA observed a covered jacuzzi in the backyard with no water.

LPA began review of client records. Two (2) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed incomplete files and a citation will be issued for the required forms.

LPA began review of employee records. Three (3) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights and training verification. LPA observed an administration certificate with expiration date 11/21/23. Administrator is in the process of the last unit for renewal completion.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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Document Has Been Signed on 11/04/2024 01:37 PM - It Cannot Be Edited


Created By: Armando Perez On 11/04/2024 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REGENCY RANCH CARE HOME
FACILITY NUMBER: 331881303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 in 1 out of 1 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Administrator will email LPA confirmation of completed course that is needed to complete the renewal process for Administrators Certification.
Type A
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

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 in two out of two clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Administrator will email LPA an updated Physician Report for two out of two clients.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Armando Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2024 01:37 PM - It Cannot Be Edited


Created By: Armando Perez On 11/04/2024 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REGENCY RANCH CARE HOME
FACILITY NUMBER: 331881303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(16)
Personal Rights of Residents in all Facilities
(16) To receive or reject medical care or other services.

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 in two]out of two clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Administrator will email a signed Medical consent form for two out two clients.
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in master bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Administrator will provide a photo of receipt of repairs done and confirmation of all lights working in the bathroom.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Armando Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/04/2024 01:37 PM - It Cannot Be Edited


Created By: Armando Perez On 11/04/2024 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REGENCY RANCH CARE HOME
FACILITY NUMBER: 331881303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

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 in two out of 3 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Administrator will email LPA Health screening reports for two out of three staff.
Type B
Section Cited
CCR
87412(a)(13)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement.

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 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Administrator will email LPA proof of completion of the final course to complete renewal requirements.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Armando Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/04/2024 01:37 PM - It Cannot Be Edited


Created By: Armando Perez On 11/04/2024 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: REGENCY RANCH CARE HOME
FACILITY NUMBER: 331881303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

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
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2
3
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Based on record review, the licensee did not comply with the section cited above in two out of three staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Administrator will email copy of valid CPR certification for two out of three staff.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

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 in one out of two clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/14/2024
Plan of Correction
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Administrator will email a signed copy of the Admissions Agreement for one out of two clients.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Armando Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: REGENCY RANCH CARE HOME
FACILITY NUMBER: 331881303
VISIT DATE: 11/04/2024
NARRATIVE
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A citation will be issued for the missing staff documents and proof of completion of the administrator certificate.

LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for knives and sharps in the kitchen.

Medications are centrally stored. There is a locked cabinet in the kitchen allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.



LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguisher was recharged and good until 05/13/2025. The facility is conducting emergency disaster/fire drills monthly; last done on 10/27/2024.

Based on the information received during this visit today in the areas reviewed, there are deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. Corrections will need to be provided to LPA by agreed upon date.

This report was reviewed with administrator Maricel Calma and a copy was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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