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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802408
Report Date: 11/05/2021
Date Signed: 11/05/2021 07:00:50 PM

Document Has Been Signed on 11/05/2021 07:00 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:REGAL CAREFACILITY NUMBER:
565802408
ADMINISTRATOR:BRODT, DONALDFACILITY TYPE:
740
ADDRESS:3316 GREENVILLE AVENUETELEPHONE:
(805) 587-2992
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 7DATE:
11/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Donald BrodtTIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management visit to the above facility. LPA met with Administrator Donald Brodt at 11:02 AM. Entrance interview conducted.

LPA along with Donald tour the facility inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 regulations.

Upon tour at 11:15 a.m., LPA counted seven (7) resident in the facility, five (5) where in the dining room, one (1) was in the living room watching television, 1 was in their room. LPA questioned Donald regarding extra resident. Donald stated that resident is staying in Bedroom #2 with another resident. LPA observed the facility sketch and fire clearance and noticed Bedroom #2 is cleared to have only 1 occupancy. Interview with resident #7 (R7) 12:00 p.m. revealed that they are staying with another resident in bedroom number #2.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of
Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in
civil penalties.

Civil penalties will be assessed against any facility that fails to take corrective action within described time
periods. The facility is hereby notified that a civil penalty will be assessed beginning on 11/5/2021. An Immediate Civil Penalty Assessment of $500.00 has been issued today 11/5/2021 for Fire Clearance.

Exit interview conducted. A copy of the report and appeal rights were provided via email to admin.


SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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 11/05/2021 07:00 PM - It Cannot Be Edited


Created By: Angel Ascencio On 11/05/2021 at 02:01 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: REGAL CARE
FACILITY NUMBER: 565802408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2021
Section Cited
CCR
87202

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87202 Fire Clearance All facilities shall maintain a fire clearance approved by the city,county,or city and county fire department, or district providing fire protection services, or the State Fire Marshal...appropriate fire clearance approved by the city,county or city and county fire department, or district providing fire protection services,or the State Fire Marshal.
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Licensee will remove resident from room and will find appropriate housing for resident. Licensee will provide photographic or statement proof of resident not resident in Bedroom #2.
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Based on documents gathered, interviews and observations the licensee did not comly with the section cited above as the facility exceeded fire clearance limitations which poses an immiedate health, safety and personal right violation to persons in care.
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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