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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701107
Report Date: 10/09/2025
Date Signed: 10/09/2025 03:22:20 PM

Document Has Been Signed on 10/09/2025 03:22 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:REGENCY PLACEFACILITY NUMBER:
342701107
ADMINISTRATOR/
DIRECTOR:		DAMION E. ANDERSONFACILITY TYPE:
740
ADDRESS:8190 ARROYO VISTA DRIVETELEPHONE:
(916) 681-7800
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 61CENSUS: 52DATE:
10/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Damion E. AndersonTIME VISIT/
INSPECTION COMPLETED:
03:41 PM
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On 10/9/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Arvin Villanueva arrived at this facility unannounced to conduct an annual inspection visit. LPAs met with Executive Director, Damion Anderson (ED) and explained the purpose of the visit.

The facility is a Residential Care Home for the Elderly, approved for age range 60 and over. Approved for 61 non-ambulatory, of which 10 may be bedridden. Approved hospice waiver for 10. ED holds Administrator Certification #7022031740 and expires 3/25/2026.

LPAs and ED inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPAs observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room were toured. Medication room was toured. Kitchen was toured for adequate food supplies and storage. A review of the facility perimeter fence, side gates, and exits was conducted. A review of the resident rooms and bathrooms were conducted.

LPAs observed the facility to be free of odor, clean and in good repair at this time. LPAs observed required furniture and lighting throughout the facility. LPAs observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Refrigerators and freezers were observed to store adequate amount of food. Temperatures for refrigerators and freezers were observed to be within regulatory standard as per observation and review of temperature log.

Report continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: REGENCY PLACE
FACILITY NUMBER: 342701107
VISIT DATE: 10/09/2025
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The hot water temperature was measured at 117.3 degrees Fahrenheit in 4 sample resident rooms. The room temperature inside the facility measured between 71 and 75 degrees Fahrenheit. Centrally stored medications, toxins, and sharp knives kept locked and inaccessible to residents. LPAs observed the fire extinguisher(s) were up to date and were last serviced on 6/25/25. Smoke and carbon monoxide detector(s) in the facility were in good repair. First aid kit was checked and are complete.

Review of 7 resident files include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Medication review of 3 residents include review of physician orders for over-the-counter medications. No issues were noted at this time. LPAs reviewed 5 staff files include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. No issues were noted at this time. Facility conducts quarterly disaster/evacuation drill and last drill was on 7/1/2024. Facility has a dementia care plan and infection control plan.

The following documents were collected during today's visit:
LIC 308 Designation of Administrative Responsibility, Proof of Current Liability Insurance, Resident Roster, LIC 500 Personnel Report and Staff Schedule for October 2025

The following documents were requested during today's visit:
Updated infection control and disaster plan

Per California Code of Regulations, Title 22, no deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report were left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2025
LIC809 (FAS) - (06/04)
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