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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701107
Report Date: 11/05/2022
Date Signed: 11/07/2022 10:31:06 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/07/2022 10:31 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:REGENCY PLACEFACILITY NUMBER:
342701107
ADMINISTRATOR:CRUZ, ELIZABETHFACILITY TYPE:
740
ADDRESS:8190 ARROYO VISTA DRIVETELEPHONE:
(916) 681-7800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 61CENSUS: 46DATE:
11/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Jane RoweTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Jane Rowe and explained the purpose of the visit. LPA was later joined by Elizabeth Cruz

LPA and Rowe inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 124.5 degrees Fahrenheit in resident's bathroom sink (room 14 and 17), which is not within the required range of 105 to 120 degrees. Water temperatures in the Memory care area was within the required range.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 10 resident and 5 staff files, including criminal record clearances. During the file review for the residents LPA observed outdated Physician's report for 4 of 5 residents reviewed. Fire drill was completed on 9/8/2022. The facilities five year riser fire system inspection was outdated. The system was last serviced on 5/2017 and LPA was unable to locate the annual service sticker.

All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2022
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 3
Document Has Been Signed on 11/07/2022 10:31 AM - It Cannot Be Edited


Created By: Albert Johnson On 11/05/2022 at 03:54 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: REGENCY PLACE
FACILITY NUMBER: 342701107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2022
Section Cited
CCR
87303(e)(2)

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87303(e)(2) Maintenance and Operation -Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105
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Administrator shall turned down the water heater to required temperature by 11/06/22. Administrator shall test the hot water each day for 3 days and send in the hot water measurement sheet to LPA by the POC 0f 11/10/2022.
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degree F (41 degree C)
and not more than 120 degree F (49 degree C)-This requirement was not met as evidenced by observation: Hot water measured at 124.5*F in residents bathroom room 14 and 17.

This poses an immediate health and safty risks to residents.
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Type A
11/06/2022
Section Cited
CCR87203

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on: Observation, The facility did not to maintained in conformity with the regulations
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Administrator will ensure that the fire equipment listed is inspected or a plan is made and sent to CCL by the POC date indicated. Licensee/Administrator shall send picture of the
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adopted by the State Fire Marshal. The five years riser fire system inspection was outdated. The system was last serviced on 5/2017 and LPA was unable to locate the annual service sticker.
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 new tags as proof and submit Statement of Compliance by POC date**Fire Clearance Civil Penalty Assessed***
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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2022 10:31 AM - It Cannot Be Edited


Created By: Albert Johnson On 11/05/2022 at 04:41 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: REGENCY PLACE
FACILITY NUMBER: 342701107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
87705(c)(5)

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Care of Persons with Dementia
Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually.
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All residents diagnosed with dementia will be scheduled with their responsible physician and be assessed for any changes to their needs with an updated LIC 602. Statement of correction, with copy of updated LIC 602, to be completed and submitted into CCL by the due date.
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LPA observed that R1 thru R4 diagnosed with dementia didn't have an updated LIC 602
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2022


LIC809 (FAS) - (06/04)
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