Inspection Reports for Regency Palms Senior Living
117 E 8th St, Long Beach, CA 90813, United States, CA, 90813
Back to Facility ProfileInspection Report Summary
Most inspections at Regency Palms Long Beach found deficiencies related primarily to medication management, resident care including incontinence and supervision, and personal rights issues such as unauthorized video surveillance. Several complaint investigations substantiated failures to administer medications properly, delays in responding to call buttons, and inadequate incontinent care, with some incidents posing potential health and safety risks. The facility also faced substantiated findings involving a questionable resident death due to lack of supervision and issues with eviction notices, though allegations of staff retaliation and rough handling were mostly unsubstantiated. Enforcement actions included civil penalties for repeat violations and failure to report incidents timely, but no license suspensions or fines were listed in the available reports. The most recent report from October 24, 2025, showed one medication administration deficiency, indicating some ongoing challenges, though many recent complaints were found unsubstantiated, suggesting partial improvement in certain areas.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 71
Capacity: 91
Deficiencies: 1
Oct 24, 2025
Visit Reason
The inspection was an unannounced one-year inspection visit conducted to evaluate compliance with licensing requirements at Regency Palms Long Beach facility.
Findings
The facility was generally compliant with Title 22 regulations, including safety, cleanliness, and disaster preparedness. However, two medication discrepancies were observed involving residents #6 and #7, where medications were documented as given but were still present in the bubble pack, posing a potential health and safety risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication administration record indicated medications were given to residents #6 and #7 as prescribed, but medication was still observed in the bubble pack, posing a potential health, safety, or personal rights risk. | Type B |
Report Facts
Residents diagnosed with dementia: 32
Residents receiving home health: 53
Residents receiving hospice care: 10
Medication discrepancies observed: 2
Resident records reviewed: 8
Staff records reviewed: 8
Resident Medication Administration Records reviewed: 8
Plan of Correction due date: Nov 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Jakini | Administrator | Met with Licensing Program Analysts during inspection and named in medication administration deficiency |
| Zina Brown | Licensing Program Analyst | Conducted inspection and documented findings |
| Lizeth Villegas | Licensing Program Analyst | Conducted inspection and medication administration record review |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 91
Deficiencies: 0
Oct 24, 2025
Visit Reason
An unannounced Case Management - Incident visit was conducted to follow up on a reported incident regarding personal rights for Resident 2 that was reported to the department on October 22, 2025.
Findings
The Licensing Program Analyst conducted a health and safety check, toured the shared bedroom of Resident 1 and Resident 2 with staff present, and obtained physician reports for both residents. Additional time was needed to complete the investigation.
Complaint Details
The visit was triggered by a complaint related to personal rights for Resident 2. The investigation was ongoing at the time of the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Jakini | Administrator | Met with Licensing Program Analyst during the inspection and involved in the exit interview. |
| Zina Brown | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 91
Deficiencies: 0
Sep 4, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff do not ensure that a resident is adequately fed and hydrated.
Findings
The investigation included interviews with staff, residents, and a witness, review of resident records and shift notes, and direct observation. The allegations were found to be unsubstantiated as evidence did not prove the alleged violations occurred.
Complaint Details
The complaint alleged that staff did not ensure that a resident was adequately fed or hydrated. The investigation found that meals and hydration were provided, meal replacements were offered when residents refused to eat, and staff encouraged residents to drink water regularly. Observations and documentation supported that the resident was provided food and water, though one witness reported an isolated oversight. Overall, the allegations were unsubstantiated.
Report Facts
Capacity: 91
Census: 75
Staff interviewed: 9
Residents interviewed: 7
End-of-shift notes reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bernadette Allen | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Robert Jakini | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 91
Deficiencies: 2
Aug 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 2025-06-19 regarding staff mishandling medications and failure to properly report incidents involving residents.
Findings
The investigation substantiated two allegations: staff mishandled a resident's medications, and staff failed to properly report an incident involving residents. Two other allegations regarding unlawful eviction and retaliation against a resident were unsubstantiated.
Complaint Details
The complaint investigation was initiated based on allegations received on 2025-06-19. The allegations included staff mishandling medications and failure to report incidents. Both allegations were substantiated based on interviews, record reviews, and evidence. Additional allegations of unlawful eviction and retaliation were investigated and found unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff failed to ensure medication for Resident 1 was administered as per the doctor's order, posing a potential health and safety risk. | Type A |
| The licensee failed to report an incident that occurred on 04/13/2025 to the licensing agency within the required timeframe, posing a potential health, safety, or personal rights risk. | Type B |
Report Facts
Capacity: 91
Census: 75
Medication pills remaining: 20
Medication pills expected remaining: 11
Plan of Correction Due Date: 2
Plan of Correction Due Date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Robert Jakini | Executive Director | Facility representative met during the investigation and named in findings |
| Kenia Sanchez Padilla | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 0
Aug 6, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the signal system was made inaccessible to a resident in care.
Findings
The investigation included testing emergency pull cords, interviewing staff and residents, and reviewing documentation. No evidence was found to support the allegation, and no deficiencies were observed or cited during the visit. The allegation was determined to be unsubstantiated.
Complaint Details
The allegation stated that the string from a resident’s emergency pull cord had been cut and tied tightly around the button, making it unable to be pulled. The investigation found all tested emergency pull cords operational, staff and residents confirmed functionality, and a prior repair was documented. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Capacity: 91
Census: 74
Staff interviewed: 7
Residents interviewed: 7
Response time: 7
Date of pull cord testing log: Jun 11, 2025
Date of work order: Jul 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation |
| Robert Jakina | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Capacity: 91
Deficiencies: 0
Jul 24, 2025
Visit Reason
An unannounced complaint investigation was conducted following allegations that staff did not put a plan in place to prevent a resident from being physically attacked by another resident and that staff did not intervene during a resident-on-resident attack.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff confirmed the existence of a dementia care plan and zero-tolerance policy for aggression. Staff intervened during the resident altercation, and no injuries occurred. The incident was self-reported timely to authorities. No deficiencies were cited.
Complaint Details
The complaint was unsubstantiated due to lack of sufficient evidence to prove the alleged violations. Staff intervened appropriately during the resident altercation, and the incident was self-reported. Residents interviewed denied the allegations.
Report Facts
Facility capacity: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Bunker | Licensing Program Analyst | Conducted the complaint investigation |
| Robert Jakina | Executive Director | Facility representative met during investigation and named in report |
| Stephanie Cifuentes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 91
Deficiencies: 0
Jul 24, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to gather information, interview staff and residents, and deliver findings regarding allegations that staff did not ensure a resident was allowed visitors and that staff verbally threatened a resident's personal representative to evict the resident.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff and residents denied the allegations, and records showed visiting hours were posted and enforced. The allegations were determined to be unsubstantiated, and no deficiencies were cited.
Complaint Details
The complaint involved two allegations: 1) Staff did not ensure a resident was allowed visitors, and 2) Staff verbally threatened a resident's personal representative to evict the resident. Both allegations were investigated through interviews and record reviews and were found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 91
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Jakini | Executive Director | Met with during the investigation and exit interview |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 91
Deficiencies: 0
Jul 14, 2025
Visit Reason
An unannounced case management visit was conducted due to substantiated allegations from a complaint received on 2025-06-19.
Findings
Two of the allegations from the complaint were substantiated, and civil penalties were assessed for deficiencies cited related to the complaint.
Complaint Details
Complaint #11-AS-20250619142057 was received on 2025-06-19, with two allegations substantiated.
Report Facts
Civil penalties assessed: Penalties assessed on 2025-07-14 for deficiencies cited on 2025-07-10 related to complaint #11-AS-20250619142057
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Jakini | Administrator | Met with Licensing Program Analyst during the inspection and exit interview |
| Zina Brown | Licensing Program Analyst | Conducted the unannounced case management deficiencies visit |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 0
Jul 10, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-07-01 regarding the facility elevators being in disrepair.
Findings
The investigation found insufficient evidence to substantiate the allegation that the facility elevators were in disrepair. Interviews with staff, residents, and the Regional Director indicated the elevator was repaired on the same day the issue was discovered, and residents and families were notified. No deficiencies were cited.
Complaint Details
The complaint alleged that the facility elevators were in disrepair and residents were unable to use them. The allegation was unsubstantiated after investigation, including interviews and record reviews. The elevator company was notified immediately on 2025-07-01, and repairs were completed the same day.
Report Facts
Capacity: 91
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robert Jakini | Executive Director | Met with during the investigation and exit interview |
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 0
Jul 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not safeguard a resident's personal belongings.
Findings
The investigation found no preponderance of evidence to support the allegation that staff lost a resident's belongings. The facility's policies and resident agreements indicated management was not responsible for lost or stolen items unless included in an inventory. Interviews with staff and residents did not reveal missing items, and no deficiencies were cited during the visit.
Complaint Details
The allegation was that staff did not safeguard a resident's personal belongings, specifically that the facility staff lost a resident's belonging. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Complaint Control Number: 11-AS-20250619171348
Staff interviewed: 11
Residents interviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fabiola Marciano | Executive Director | Met with Licensing Program Analyst during visit |
| Lisa To | Regional Director | Participated in exit interview |
| Kenia Sanchez Padilla | Administrator | Facility administrator named in report header |
| Eva M Alvarez | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 2
Jul 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-06-19 regarding allegations of staff mishandling medications and failure to properly report incidents involving residents.
Findings
The investigation substantiated two allegations: staff mishandled a resident's medications and staff failed to properly report an incident involving residents. Two other allegations regarding unlawful eviction and retaliation against a resident were unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for allegations that staff mishandled a resident's medications and did not properly report incidents involving residents. The investigation included interviews with staff, residents, and review of records. Two allegations regarding unlawful eviction and retaliation were unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff failed to ensure medication for Resident 1 was administered as per doctor's order, posing a potential health and safety risk. | Type A |
| Facility failed to report an incident that occurred on 04/13/2025 to the Department of Social Services in a timely manner. | Type B |
Report Facts
Medication pills remaining: 20
Medication pills expected remaining: 11
Facility capacity: 91
Census: 74
Plan of Correction due date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits. |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Robert Jakini | Executive Director | Met with Licensing Program Analyst during visits and was provided findings. |
| Kenia Sanchez Padilla | Administrator | Facility administrator interviewed during investigation. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 0
Jul 1, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff failed to reassess a resident properly.
Findings
The investigation found that the LIC 602A form was completed and signed by the resident's primary care physician, not by the facility staff, and the service plan was not signed by the resident's Power of Attorney. Interviews and record reviews did not find sufficient evidence to support the allegation, resulting in an unsubstantiated finding.
Complaint Details
The complaint alleged that facility staff failed to reassess resident (R#1) properly. The allegation was found to be unsubstantiated based on evidence gathered, interviews conducted, and records reviewed.
Report Facts
Facility capacity: 91
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Monique Avila | Wellness Director | Met with the Licensing Program Analyst during the investigation |
| Kenia Sanchez Padilla | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 0
Jun 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging that staff were not taking universal precautions to prevent the spread of COVID-19.
Findings
The investigation included interviews with residents and staff, review of infection control plans, incident reports, and communications with health authorities. The findings showed that staff and residents were observed wearing masks, infection control training was provided, and COVID-19 protocols were followed. The allegation was unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff were not taking universal precautions to ensure COVID-19 was not spread. The investigation found no substantiated violation; residents and staff denied the allegation, and infection control measures were in place and followed.
Report Facts
Capacity: 91
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monique Avila | Wellness Director | Met with Licensing Program Analyst during the investigation |
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 0
Jun 25, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that a resident sustained unexplained injuries while in care.
Findings
The investigation included interviews with residents and staff, review of resident records, and a facility tour. The allegation was unsubstantiated due to lack of preponderance of evidence, with multiple residents and staff denying the allegation and documentation indicating the resident's bruising was self-inflicted.
Complaint Details
Allegation: Resident sustained unexplained injuries while in care. Interviews with 6 residents and 5 staff denied the allegation. Resident notes indicated self-inflicted bruising. Responsible party reported no current safety concerns. The allegation was unsubstantiated.
Report Facts
Capacity: 91
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lizeth Villegas | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Monique Avila | Wellness Director | Met with during the investigation |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
| Kenia Sanchez Padilla | Administrator | Facility Administrator named in report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 91
Deficiencies: 1
Jun 18, 2025
Visit Reason
This was an unannounced complaint investigation visit conducted to investigate allegations received on 2025-05-13 regarding illegal eviction and staff retaliation against a resident at Regency Palms Long Beach facility.
Findings
The investigation substantiated the allegation of illegal eviction due to failure to provide a valid Notice to Quit with required details per Title 22 regulations. The allegation of staff retaliation against the resident resulting in eviction was found unsubstantiated based on interviews, record reviews, and observations.
Complaint Details
The complaint involved two main allegations: 1) Staff retaliated against a resident resulting in eviction, which was unsubstantiated; 2) Illegal eviction due to defective eviction notice, which was substantiated. The investigation included interviews with staff, resident, and witness, and review of relevant documents. The illegal eviction notice was dismissed and corrected during the investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide a valid Notice to Quit per Title 22 Regulation 87244(d), lacking specific facts to permit determination of the date, place, witnesses, and circumstances concerning the eviction reasons. | Type B |
Report Facts
Capacity: 91
Census: 75
Deficiencies cited: 1
Plan of Correction Due Date: Jun 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Fabiola Marciano | Executive Director | Facility representative met during the investigation |
| Kenia Sanchez Padilla | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 91
Deficiencies: 1
Jun 18, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that a resident was not assisted with medications as prescribed.
Findings
The investigation found sufficient evidence that facility staff failed to administer medication to a resident at the prescribed time, confirming the allegation as substantiated. The medication was given late after being initially missed, posing a potential health and safety risk.
Complaint Details
The complaint alleged that facility staff did not give a resident medication as prescribed. The allegation was substantiated based on interviews, record reviews, and video evidence showing medication was administered late after being missed at the scheduled time.
Deficiencies (1)
| Description |
|---|
| Facility staff failed to ensure medication for a resident was administered as per the doctor's order, violating CCR 87465(a)(4) regarding assistance with self-administered medications. |
Report Facts
Capacity: 91
Census: 75
Plan of Correction Due Date: Jun 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Fabiola Marciano | Executive Director | Met with investigator during the visit |
| Monique Avila | Wellness Director | Met with investigator and received exit interview and complaint report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 91
Deficiencies: 0
Jun 13, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-06-05 regarding staff not preventing a resident from sustaining an unexplained injury.
Findings
The investigation found insufficient evidence to substantiate the allegation that staff failed to prevent a resident from sustaining an unexplained injury. Interviews, records review, and observations did not provide a preponderance of evidence to prove the alleged violation occurred.
Complaint Details
The complaint alleged that a resident (R1) had unexplained bruising under the left eye. Interviews with staff, residents, and the administrator, as well as a review of incident reports and resident records, were conducted. One staff member confirmed the allegation, six were unaware, and one did not confirm or deny. One resident acknowledged the bruise but was unaware of how it occurred. The allegation was determined to be unsubstantiated due to lack of sufficient evidence.
Report Facts
Facility capacity: 91
Census: 75
Staff interviewed: 7
Residents interviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit |
| Fabiola Marciano | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Kenia Sanchez Padilla | Administrator | Interviewed regarding the allegation and aware of incident report |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 91
Deficiencies: 2
Jun 6, 2025
Visit Reason
An office visit was held on 06/06/2025 to issue deficiencies identified during an unrelated complaint investigation regarding the use of video surveillance with audio components in resident bedrooms.
Findings
The facility was found to be in violation of its approved Plan of Operation and Admission Agreement by allowing video surveillance with audio capabilities in four resident bedrooms, violating the privacy rights of 2 out of 7 residents. The surveillance was installed by residents' families without consent, and the facility staff did not have access to the recordings.
Complaint Details
The visit was complaint-related due to information received about video surveillance with audio in four resident bedrooms. The complaint was substantiated as the facility violated privacy rights of residents by allowing unauthorized surveillance.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility is not following the approved plan of operation by allowing the use of video surveillance in four resident rooms. | Type B |
| Violation of residents' right to privacy by allowing video surveillance with audio in residents' rooms without consent. | Type B |
Report Facts
Residents with privacy violation: 2
Resident rooms with surveillance: 4
Census: 75
Total capacity: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fabiola Marciano | Executive Director | Met during inspection and exit interview. |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager. |
| Zina Brown | Licensing Program Analyst | Named in report as Licensing Program Analyst. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 1
May 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was not assisted with medications as prescribed.
Findings
The investigation substantiated that facility staff failed to follow the prescribed medication order for a resident, administering medication for nine consecutive days beyond the physician's discontinuation date. Another allegation regarding improper use of restraints was found to be unsubstantiated.
Complaint Details
The complaint alleged that a resident was not assisted with medications as prescribed. The allegation was substantiated based on interviews, record reviews, and evidence that medication was administered beyond the prescribed discontinuation date. Another complaint alleging improper restraint use was unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Facility staff failed to ensure medication for a resident was administered accurately, not following the prescribed medication order. |
Report Facts
Capacity: 91
Census: 74
Days medication administered beyond order: 9
Staff interviewed: 3
Residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Kenia Sanchez Padilla | Administrator | Facility administrator interviewed regarding medication order follow-up |
| Monique Avila | Wellness Director | Met with during the investigation and received the complaint report |
| Fabiola Marciano | Executive Director | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 0
May 23, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations of staff retaliation against a resident resulting in eviction and an illegal eviction at Regency Palms Long Beach facility.
Findings
The investigation found no evidence to support the allegations of staff retaliation or illegal eviction. Interviews with staff, the resident, and a witness, as well as review of records, showed that the eviction notice was invalidated and there was no mistreatment or retaliation against the resident. The allegations were determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff retaliated against Resident #1 resulting in eviction and that the eviction was illegal due to a defective notice. The investigation included interviews with staff, the resident, and a witness, and review of relevant documents. The allegations were found to be unsubstantiated due to lack of evidence.
Report Facts
Capacity: 91
Census: 74
Number of staff interviewed: 3
Dates of documents reviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Fabiola Marciano | Executive Director | Facility representative met during investigation and exit interview |
| Kenia Sanchez Padilla | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 1
May 23, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate an allegation that staff did not provide adequate supervision to residents in care.
Findings
The investigation substantiated the allegation that staff did not provide adequate supervision due to a malfunctioning emergency pull chord in room 302B that did not transmit an auditory signal to staff, posing a potential health and safety risk. Interviews with staff and residents mostly denied the allegation, but the device failure was confirmed by observation and records.
Complaint Details
The complaint alleged that an alarm was going off in a resident’s room from 9:00am to 9:25am on 05/19/2025, but no staff responded to check on the resident. The investigation included interviews with staff and residents, document reviews, and observation of the emergency pull chord system, which was found to be malfunctioning and not transmitting an auditory signal.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Emergency signal system in room 302B does not transmit an auditory signal to a central staffed location, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 91
Census: 74
Deficiency due date: Jun 13, 2025
Fine amount: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fabiola Marciano | Executive Director | Met with during investigation and exit interview |
| Perry Scott | Licensing Program Analyst | Conducted the complaint investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 1
May 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to a complaint alleging that staff did not respond to residents' requests for assistance in a timely manner and that staff did not ensure a resident's monitoring device was properly placed.
Findings
The investigation substantiated that staff did not respond to residents' pull cord alarms in a timely manner, with documented response times up to nearly 4 hours. However, the allegation that staff did not ensure a resident's monitoring device was properly placed was found to be unsubstantiated after review and inspection.
Complaint Details
The complaint alleged that staff did not respond promptly to residents’ requests for assistance, with specific incidents showing response times ranging from over 1 hour to nearly 4 hours. Interviews with residents and staff confirmed delays longer than the facility's stated 10-minute response time. The allegation regarding improper placement of a resident’s monitoring device was investigated and found unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff are not answering residents’ pull cords in a timely manner, posing a potential health and safety risk. | Type B |
Report Facts
Facility census: 74
Facility capacity: 91
Maximum staff response time: 233
Other recorded response times: 103
Other recorded response times: 170
Other recorded response times: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenia Sanchez Padilla | Administrator | Provided statements regarding facility pull alarm system and response times |
| Monique Avila | Wellness Director | Met with Licensing Program Analyst during investigation and received copy of complaint report |
| Fabiola Marciano | Executive Director | Met with Licensing Program Analyst during investigation |
| Alfonso Iniguez | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 0
May 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation regarding an allegation that the licensee initiated an eviction process in retaliation against a resident.
Findings
Based on interviews with staff and residents, and review of records including reassessments and progress notes, there was insufficient evidence to substantiate the allegation. The eviction was determined to be due to the resident requiring a higher level of care and supervision. No deficiencies were cited.
Complaint Details
The complaint alleged that the licensee initiated eviction in retaliation against a resident. The investigation included interviews with three staff members and two residents, review of facility records, and progress notes. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 91
Census: 74
Eviction notice date: Apr 15, 2025
Eviction notice period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Fabiola Marciano | Executive Director | Interviewed during investigation |
| Monique Avila | Wellness Director | Received a copy of the report during exit interview |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 3
May 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation initiated due to allegations received on 02/01/2023 concerning questionable death and failure to ensure postural support was used as prescribed at Regency Palms Long Beach.
Findings
The investigation substantiated two allegations: a questionable death of a resident left unsupervised with a safety belt on resulting in aspiration and death, and staff failing to use postural support as prescribed causing the resident to slide out of the wheelchair. A third allegation regarding unsecured medication was unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations of questionable death and failure to ensure postural support was used as prescribed. The questionable death involved resident R1 being left unsupervised with a safety belt on the wheelchair, leading to aspiration and death. The postural support allegation involved staff failing to use the safety belt as ordered, causing the resident to slide out of the wheelchair. The medication security allegation was unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Staff #1 failed to provide supervision of resident R1 while using a postural support (belt), resulting in the resident's death after being left unsupervised for over 45 minutes. | Type A |
| Staff failed to use the prescribed postural support (safety belt) which resulted in resident R1 sliding out of the wheelchair. | Type B |
| Facility staff were aware of changes in resident R1's physical limitations and inability to be left unsupervised, but there was no documented appraisal of these changes. | Type B |
Report Facts
Civil penalty: 500
Capacity: 91
Census: 74
Plan of Correction Due Date: May 21, 2025
Plan of Correction Due Date: May 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sparkle Day | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation. |
| Carla Mariano | Administrator | Facility administrator interviewed during the investigation and named in findings. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 2
May 8, 2025
Visit Reason
An unannounced Case Management visit was conducted to issue deficiencies found during a complaint investigation related to unauthorized video surveillance in resident rooms.
Findings
The facility violated residents' personal rights by allowing video surveillance with audio in shared resident rooms without consent forms or an approved waiver, failing to comply with its Plan of Operation and Title 22 regulations.
Complaint Details
The visit was triggered by complaint investigation 11-AS-20250417101102 regarding unauthorized video surveillance in shared resident rooms. The complaint was substantiated by interviews and record reviews.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility is not following the approved plan of operation by allowing the use of video surveillance in resident rooms, posing a personal rights risk to residents. | Type B |
| Residents #1-7 have video surveillance with audio component; 5 of 7 residents are in shared rooms where surveillance is located without consent forms or approved waiver. | Type B |
Report Facts
Residents with video surveillance: 7
Residents in shared rooms with surveillance: 5
Plan of Correction due dates: Jun 8, 2025
Plan of Correction due dates: Jun 9, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fabiola Marciano | Executive Director | Met during inspection and named in findings related to video surveillance. |
| Zina Brown | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 0
May 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not assist a resident with care needs in a timely manner.
Findings
The investigation found no preponderance of evidence to support the allegation. Observations and interviews indicated that staff generally assisted residents in a timely manner, and no deficiencies were cited during the visit.
Complaint Details
The allegation was that staff did not assist a resident with putting bottoms on while in bed until hours later. Interviews with staff and residents, as well as record reviews, showed that assistance was typically timely. One resident reported a delay due to a low battery in the pendant. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Capacity: 91
Census: 74
Staff interviewed: 11
Residents interviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fabiola Marciano | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Kenia Sanchez Padilla | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 2
May 2, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident had multiple falls in care and that the facility failed to report an incident.
Findings
The investigation substantiated that Resident #1 experienced multiple falls over the past two months with injuries, and the facility failed to submit required incident reports for these falls and other incidents. The facility lacked a fall management plan after reassessment, posing a health and safety risk.
Complaint Details
The complaint alleged that Resident #1 had multiple falls in care and that the facility failed to report an incident. The investigation confirmed multiple falls with injuries and failure to report incidents as required by regulations. The allegations were substantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #1 had several falls with no reappraisal to address significant health changes with a fall management plan. | Type B |
| Resident #1 had several falls and failed to submit a written incident report to Community Care Licensing for the 03/31/25 incident and seven other incidents in April 2025. | Type B |
Report Facts
Falls: 4
Unreported incidents: 7
Capacity: 91
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fabiola Marciano | Executive Director | Interviewed during the investigation and named in findings regarding fall incidents and reporting failures |
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Follow-Up
Census: 73
Capacity: 91
Deficiencies: 1
Apr 23, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on a previously cited deficiency regarding personal rights privacy related to video surveillance cameras in residents' rooms.
Findings
The inspection found that five residents currently have video surveillance cameras in their bedrooms, which poses a personal rights risk. A deficiency was cited based on this finding under California Code of Regulation Title 22 Division 6 Chapter 8.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Five residents have surveillance video cameras in their bedrooms which poses a personal rights risk to residents in care. | Type A |
Report Facts
Residents with video surveillance cameras: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fabiola Marciano | Executive Director | Interviewed regarding the deficiency and visit |
| Zina Brown | Licensing Program Analyst | Conducted the inspection visit |
| Janae Hammond | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 91
Deficiencies: 0
Apr 23, 2025
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the licensee initiated an eviction process in retaliation against a resident.
Findings
The investigation found insufficient evidence to support the allegation of retaliatory eviction. The facility followed proper procedures for eviction based on the resident's increased care needs, and no deficiencies were cited.
Complaint Details
The allegation was that the licensee initiated eviction in retaliation against the resident. The investigation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 91
Census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Antonine Richard | Licensing Program Analyst | Conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on report |
| Fabiola Marciano | Executive Director | Interviewed during investigation and received report copy |
| Kenia Sanchez Padilla | Administrator | Facility Administrator listed in report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 91
Deficiencies: 1
Apr 11, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to a complaint received on 2025-03-20 alleging that staff leaves residents soiled for an extended period of time.
Findings
The investigation substantiated the allegation that residents were left in soiled pull-ups or diapers for extended periods. Interviews with staff, residents, and witnesses, as well as record reviews, confirmed that timely incontinent care was not consistently provided to residents R1, R2, R4, R5, and R6.
Complaint Details
The complaint alleged that staff left a resident soiled for an extended period. The investigation found the allegation substantiated based on observations, interviews with staff, residents, and witnesses, and record reviews. The preponderance of evidence standard was met.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents R1, R2, R4, R5, and R6 were provided timely incontinent care to keep them clean and dry. | Type B |
Report Facts
Capacity: 91
Census: 71
Deficiency Type B: 1
Plan of Correction Due Date: Apr 21, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Robin Walker | Resident Care Coordinator | Met with Licensing Program Analyst during investigation and exit interview |
| Kenia Sanchez Padilla | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 91
Deficiencies: 2
Mar 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-02-24 regarding medication assistance, falsification of resident records, and safeguarding of resident personal belongings.
Findings
The investigation substantiated allegations that staff failed to provide medication assistance properly and falsified medication administration records, posing immediate health and safety risks. However, the allegation regarding failure to safeguard resident personal belongings was unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not provide medication assistance to residents and falsified resident medication records. One allegation regarding failure to safeguard resident personal belongings was unsubstantiated. A civil penalty was assessed for a repeat violation within the last 12 months.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff failed to ensure medication for 7 out of 7 resident medications reviewed was administered accurately, posing an immediate health and safety risk. | Type A |
| Staff failed to ensure that a separate, complete, and current record was maintained for each resident, with medications signed off as administered but not given. | Type A |
Report Facts
Residents with medication discrepancies: 7
Residents with medications signed off but not administered: 3
Staff admitting to signing off medication not provided: 4
Residents reporting not receiving medications as prescribed: 1
Residents declining inventory of personal belongings: 8
Residents reporting missing personal belongings: 4
Staff reporting clothing mix-up or taking other residents' belongings: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Fabiola Marciano | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview. |
| Kenia Sanchez Padilla | Administrator | Named as facility administrator in the report. |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 91
Deficiencies: 0
Mar 4, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to a complaint alleging that the licensee does not maintain the facility in good repair, specifically regarding the main elevator, washer and dryer, and refrigerator not working.
Findings
The investigation included interviews with staff and residents, facility tour, and document review. The elevators were found operational, refrigerators were working with temperatures within acceptable ranges, and the third-floor refrigerator had been replaced after a work order. Staff and residents acknowledged occasional elevator issues but confirmed current functionality. No evidence was found to substantiate the complaint.
Complaint Details
The complaint alleged that the main elevator, washer and dryer, and refrigerator were not working. The investigation found the elevator operational with monthly maintenance, washers and dryers working though dryers take longer, and refrigerators functioning properly. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 91
Census: 73
Refrigerator temperature: 60
Refrigerator temperatures: 38
Refrigerator temperatures: -1
Refrigerator temperatures: 35
Refrigerator temperatures: 0
Refrigerator temperatures: 40
Refrigerator temperatures: -3
Refrigerator temperatures: 34
Refrigerator temperatures: -4
Refrigerator temperatures: 35
Refrigerator temperatures: -1
Refrigerator temperatures: 36
Refrigerator temperatures: -2
Refrigerator temperatures: 36
Refrigerator temperatures: -1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Fabiola Marciano | Executive Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Follow-Up
Census: 72
Capacity: 91
Deficiencies: 1
Feb 3, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on a deficiency regarding hot water temperatures in the facility.
Findings
The inspection found that several resident rooms had hot water temperatures below the required range of 105 to 120 degrees Fahrenheit. A civil penalty assessment for failure to correct the deficiency is being issued.
Deficiencies (1)
| Description |
|---|
| Resident rooms had hot water temperatures below the required 105-120°F range (Room 602: 104°F; Room 502: 99°F; Room 504: 104.2°F; Room 406: 100.9°F). |
Report Facts
Hot water temperature readings: 99
Hot water temperature readings: 104
Hot water temperature readings: 104.2
Hot water temperature readings: 100.9
Facility census: 72
Facility capacity: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fabiola Marciano | Executive Director | Met with during inspection and explained purpose of visit |
| Mary Ruffin | Resident Care Coordinator | Received copy of report and appeal rights |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 91
Deficiencies: 2
Jan 6, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including staff not securing residents' medications, not ensuring residents' incontinence needs are met, and not answering residents' call buttons in a timely manner.
Findings
The investigation found the allegation regarding unsecured medications unsubstantiated due to insufficient evidence. However, allegations that staff did not meet residents' incontinence needs and did not respond timely to call buttons were substantiated based on interviews, record reviews, and observations. Deficiencies were cited for incontinence care and staff response times, with a civil penalty assessed due to repeat violations.
Complaint Details
The complaint investigation was triggered by allegations that staff did not secure residents' medications, did not ensure residents' incontinence needs were met, and did not answer call buttons timely. The medication allegation was unsubstantiated. The incontinence care and call button response time allegations were substantiated. A civil penalty was assessed due to repeat violations related to incontinence care.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure incontinent residents are checked during known incontinent periods, including nighttime. | Type B |
| Failure to provide care, supervision, and services that meet residents' individual needs with sufficient staff competency and numbers. | Type B |
Report Facts
Incidents of delayed response to pull cords: 32
Residents requiring incontinence care with missing documentation: 3
Incidents by duration of delayed response: 1
Incidents by duration of delayed response: 3
Incidents by duration of delayed response: 9
Incidents by duration of delayed response: 2
Incidents by duration of delayed response: 1
Incidents by duration of delayed response: 5
Incidents by duration of delayed response: 11
Incidents occurring at nighttime: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fabiola Marciano | Executive Director | Met with during the investigation and referenced regarding staff response time standards. |
| Socorro Leandro | Licensing Program Analyst | Conducted the complaint investigation and signed the report. |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation. |
| Kenia Sanchez Padilla | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 91
Deficiencies: 1
Dec 17, 2024
Visit Reason
The Department of Social Services conducted a Case Management visit to deliver an additional deficiency related to a complaint about staff handling a resident in a rough manner on 11/20/2024.
Findings
The investigation found that Staff 1 handled a resident roughly, witnessed by two individuals. The Resident Care Coordinator and Executive Director were informed but failed to submit the required Unusual Incident/Injury Report to the licensing agency within seven days, resulting in a deficiency citation for failure to comply with reporting requirements.
Complaint Details
Complaint Control Number: 11-AS-20241125165223. The complaint involved staff handling a resident in a rough manner on 11/20/2024. The deficiency was substantiated based on interviews and record review.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a written report to the licensing agency within seven days of an incident involving psychological abuse of a resident by staff on 11/20/2024. | Type B |
Report Facts
Deficiency Plan of Correction Due Date: Jan 7, 2025
Capacity: 91
Census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fabiola Marciano | Executive Director | Met during the visit and involved in the deficiency regarding failure to report incident |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 91
Deficiencies: 2
Dec 17, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff handled a resident in a rough manner.
Findings
The investigation substantiated the allegation that Staff 1 physically removed Resident 1 in a rough manner, violating the facility's Dementia Care Plan and residents' personal rights. Deficiencies were cited related to personal rights violations and inadequate care of persons with dementia.
Complaint Details
The complaint alleged that staff handled a resident in a rough manner. The investigation included interviews with staff, residents, and witnesses, and review of facility records. The allegation was substantiated based on evidence that Staff 1 physically removed a resident with dementia from another resident's room contrary to the facility's care plan.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Violation of residents' personal rights by physically removing a resident from a room, causing punishment, humiliation, or abuse. | Type B |
| Failure to comply with care requirements for persons with dementia, including inadequate redirection and safety measures. | Type B |
Report Facts
Capacity: 91
Census: 69
Deficiency count: 2
Plan of Correction Due Date: Jan 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenia Sanchez Padilla | Administrator | Named as facility administrator |
| Fabiola Marciano | Executive Director | Met with licensing staff during the investigation and named in findings |
| Socorro Leandro | Licensing Program Analyst | Conducted the complaint investigation |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 91
Deficiencies: 1
Dec 16, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not adequately assist a resident with incontinence care needs in a timely manner.
Findings
The investigation found that facility staff did not assist the resident during periods when they were known to be incontinent, with documented delays in response to pull cord alerts, posing a possible health and safety risk. The allegation was substantiated based on interviews and records reviewed.
Complaint Details
The complaint alleged that staff did not adequately assist a resident with incontinence care needs in a timely manner. The complaint was substantiated based on interviews with staff and residents, and review of facility records including incontinence logs and pull cord response times.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure incontinent residents are checked during known incontinent periods, including during the night, as evidenced by delayed response to pull cord alerts. | Type B |
Report Facts
Pull cord alerts with delayed response: 51
Pull cord alerts with delayed response: 8
Plan of Correction due date: Dec 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Kenia Sanchez Padilla | Administrator | Facility administrator named in the report |
| Robin Walker | Resident Care Coordinator | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 91
Deficiencies: 1
Dec 16, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding facility staff not responding timely to pull cord alerts from residents requesting assistance.
Findings
The investigation found that facility staff did not assist a resident after being alerted in a timely manner, posing a possible health and safety risk to persons in care.
Complaint Details
The visit was complaint-related and substantiated by findings that staff failed to respond timely to resident alerts.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff did not assist resident R-1 after being alerted in a timely manner, violating Additional Personal Rights of Residents in Privately Operated Facilities under California Code of Regulations Title 22. | Type B |
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Dec 30, 2024
Staff interviewed: 7
Residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Fabiola Mariano | Administrator | Met with the Licensing Program Analyst during the inspection and exit interview |
| Robin Walker | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation |
| Stephanie Cifuentes | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 91
Deficiencies: 1
Nov 18, 2024
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not administer medication to residents as prescribed.
Findings
The investigation substantiated the allegation that medication was not administered as prescribed. Interviews with staff and residents, along with medication record reviews, revealed missing medications and unsigned medication administration records, posing an immediate health and safety risk.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews. Two out of four staff interviews confirmed the allegation, and three out of six residents confirmed awareness of the issue. Medication administration records showed missing medications and unsigned entries.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator failed to ensure medication for 8 out of 8 resident medications reviewed was administered accurately, posing an immediate health and safety risk. | Type A |
Report Facts
Civil penalty amount: 250
Deficiencies cited: 1
Medication records reviewed: 8
Residents interviewed: 6
Staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fabiola Mariano | Administrator | Met during investigation and exit interview. |
| Zina Brown | Licensing Program Analyst | Conducted the complaint investigation. |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 91
Deficiencies: 0
Nov 6, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff neglect resulted in a resident falling.
Findings
The investigation found no sufficient evidence to support the allegation of staff neglect causing resident falls. Interviews with staff and residents all denied any falls due to staff neglect, and no special incident reports of falls were found. The allegation was determined to be unsubstantiated.
Complaint Details
Allegation: Staff neglect resulted in resident falling. The allegation was unsubstantiated after review of records, interviews with staff and residents, and facility observations.
Report Facts
Capacity: 91
Census: 67
Staff interviewed: 7
Residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Felisa Shirley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stephanie Cifuentes | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Kenia Sanchez Padilla | Administrator | Facility administrator mentioned in the report |
| Robin Walker | Resident Care Coordinator | Met with Licensing Program Analyst during investigation |
Inspection Report
Annual Inspection
Census: 68
Capacity: 91
Deficiencies: 0
Oct 31, 2024
Visit Reason
The visit was an unannounced one-year inspection conducted to evaluate compliance with licensing regulations and facility standards.
Findings
The facility was found to be in compliance with all applicable regulations, with no deficiencies observed. Resident rooms, bathrooms, medication administration, kitchen, safety equipment, and grounds were all inspected and found satisfactory.
Report Facts
Residents diagnosed with dementia: 35
Residents receiving home health: 4
Residents receiving hospice care: 10
Memory care beds and residents: 13
Rooms per floor: 8
Floors in building: 10
Water temperature range (F): 118
Water temperature range (F): 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fabiola Mariano | Executive Director | Met during inspection and exit interview |
| Zina Brown | Licensing Program Analyst | Conducted the inspection |
| Lizeth Villegas | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 91
Deficiencies: 2
Oct 2, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not give resident medication and that staff were not documenting medications properly.
Findings
The investigation substantiated both allegations. Medication Administration Records for five residents showed missed medications and blank spaces without proper documentation. Interviews with staff and residents supported these findings, indicating a failure to administer and document medications properly.
Complaint Details
The complaint investigation was substantiated based on evidence gathered, interviews conducted, and records reviewed. The allegations that staff did not give resident medication and that staff were not documenting medications properly were both found to be substantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to assist residents with self-administered medications as needed, evidenced by missed medications for residents 1-5 in September 2024. | Type B |
| Failure to maintain a separate, complete, and current record for each resident, evidenced by blank spaces on Medication Administration Records without charting codes. | Type B |
Report Facts
Capacity: 91
Census: 67
Deficiencies cited: 2
Plan of Correction Due Date: Oct 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Troy Watson | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Stephanie Cifuentes | Licensing Program Manager | Oversaw the complaint investigation |
| Fabiola Mariano | Executive Director | Facility representative during the investigation and exit interview |
| Robin Walker | Wellness Director | Facility staff involved in the investigation and responsible for medication documentation |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 91
Deficiencies: 0
Aug 14, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff do not treat residents with respect and that staff handle residents roughly.
Findings
The investigation included interviews with staff and residents, review of relevant documents, and facility tour. No evidence was found to substantiate the allegations; staff and residents uniformly denied inappropriate behavior or rough handling. No deficiencies were observed or cited during the visit.
Complaint Details
The complaint alleged that staff were cussing at residents and handling residents roughly. Interviews with 12 staff and 10 residents found no evidence to support these allegations. Staff acknowledged inappropriate language among themselves but not directed at residents. The allegations were determined to be unsubstantiated due to lack of evidence.
Report Facts
Staff interviewed: 12
Residents interviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Fabiola Marciano | Administrator | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 82
Capacity: 91
Deficiencies: 1
May 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not seek timely medical care for a resident, forced a resident to shower, and handled a resident in a rough manner.
Findings
The allegation that staff did not seek timely medical care for a resident was substantiated based on interviews and record review. The allegations that staff forced a resident to shower and handled a resident in a rough manner were found to be unsubstantiated.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not seek timely medical care for resident R1. The allegations that staff forced the resident to shower and handled the resident in a rough manner were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided. This requirement is not met as evidenced by failure to seek timely medical care for resident R1 on 10/02/2023. | Type B |
Report Facts
Capacity: 91
Census: 82
Deficiency count: 1
Incident date: Mar 22, 2023
Training date: Mar 23, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ulysses Coronel | Licensing Program Manager | Oversaw the complaint investigation |
| Fabiola Marciano | Director | Facility director interviewed during investigation and recipient of report |
| Kenia Sanchez Padilla | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 91
Deficiencies: 0
Mar 11, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that the facility failed to obtain the resident’s representative admission agreement signature at the time of and as a condition of admission.
Findings
The investigation found that the resident’s admission agreement was signed by the resident’s fiduciary Power of Attorney, who was responsible for handling finances and fees. There was no preponderance of evidence to prove the allegation, and therefore it was unsubstantiated. No deficiencies were observed or cited during the visit.
Complaint Details
The allegation was that the facility failed to obtain the resident’s representative admission agreement signature at the time of and as a condition of admission. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Facility capacity: 91
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kenia Sanchez Padilla | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 91
Deficiencies: 0
Mar 11, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations that the facility failed to follow a resident's advance health care directive and that facility staff were falsifying records.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents confirmed proper notification of agents on the advance health care directive and denied any falsification of records. No deficiencies were observed or cited during the visit.
Complaint Details
The complaint involved two allegations: 1) failure to follow a resident's advance health care directive, specifically regarding notification of agents, and 2) falsification of communication records by staff. Both allegations were found to be unsubstantiated after review of records, interviews with staff and residents, and file examination.
Report Facts
Capacity: 91
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Kenia Padilla-Sanchez | Executive Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Carla Mariano | Administrator | Named as facility administrator in the report |
| Meriza De La Cruz | Former Director of Wellness | Referenced in investigation findings regarding clarification of resident's advance health care directive |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 91
Deficiencies: 0
Mar 11, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff failed to safeguard a resident's belongings.
Findings
The investigation found no evidence to substantiate the allegation that Resident R1's jewelry and personal items were unaccounted for after their death. No deficiencies were observed or cited during the visit.
Complaint Details
The allegation was that Resident R1’s jewelry and other personal items remained unaccounted for after the death of R1. The investigation reviewed admission agreements, personal property forms, and interviewed staff and residents. Staff and residents reported no observation or loss of jewelry. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Capacity: 91
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy Gibbs | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kenia Sanchez Padilla | Executive Director | Met with Licensing Program Analyst during the investigation and provided information |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 91
Deficiencies: 2
Mar 2, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of neglect and lack of timely medical treatment for a resident who sustained multiple falls and an injury.
Findings
The investigation substantiated that Resident #1 sustained multiple falls resulting in injury and that staff did not seek timely medical treatment, delaying care by four days after the last fall. Deficiencies were cited related to incidental medical and dental care and care of persons with dementia, with civil penalties assessed.
Complaint Details
The complaint alleged neglect and lack of supervision resulting in multiple falls and injury to Resident #1, and failure of staff to seek timely medical treatment. Both allegations were substantiated based on evidence and interviews.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide timely medical treatment for Resident #1's injury sustained on 06/27/21, with treatment delayed until 07/01/21. | Type A |
| Failure to implement an adequate plan of action for Resident #1, a high-risk fall resident with dementia, posing immediate health and safety risks. | Type A |
Report Facts
Capacity: 91
Census: 62
Days delay in medical treatment: 4
Immediate Civil Penalty: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Janae Hammond | Licensing Program Manager | Oversaw the complaint investigation |
| Fabiola Mariano | Wellness Director | Facility representative interviewed during investigation and named in exit interview |
| Carla Mariano | Administrator | Facility administrator mentioned in relation to initial visit and file requests |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 91
Deficiencies: 1
Jan 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations received on 2023-02-06 regarding insufficient staffing to prevent falls, answer call buttons timely, and meet resident needs for incontinence care and showering.
Findings
The investigation substantiated that facility personnel were not sufficient in numbers at all times to prevent residents from falling, answer call buttons timely, and meet resident needs for incontinence care and showering. Staffing issues were confirmed through interviews with staff and review of training and care logs.
Complaint Details
The complaint was substantiated. Allegations included insufficient staffing to prevent falls, answer call buttons timely, and meet resident needs for incontinence care and showering. Interviews with administrator, staff, and review of training and logs supported the findings. Residents interviewed were unable to communicate due to impairments.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by inadequate staffing posing a potential health risk to residents. | Type B |
Report Facts
Resident to staff ratio: 8
Facility capacity: 91
Resident census: 52
Plan of Correction due date: Jan 31, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenia Padilla | Administrator | Interviewed during the investigation and provided statements regarding staffing. |
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation and interviews. |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 91
Deficiencies: 0
Jan 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations of staff neglect in properly cleaning a resident during incontinent care and staff not following medical orders.
Findings
The investigation found the allegations to be unsubstantiated based on interviews, observations, and review of training and care records. Staff were trained and followed medical orders regarding incontinent care and wound care, and residents expressed satisfaction with the services provided.
Complaint Details
The complaint alleged staff neglect in properly cleaning resident R1 during incontinent care and failure to follow medical orders related to wound care. The investigation included interviews with staff, residents, witnesses, and review of training and care plans. The findings were unsubstantiated.
Report Facts
Capacity: 91
Census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Kenia Sanchez Padilla | Administrator | Facility administrator involved in interviews and exit interview |
| Ulysses Coronel | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 61
Capacity: 91
Deficiencies: 0
Oct 27, 2023
Visit Reason
An unannounced annual inspection visit was conducted to evaluate compliance with regulatory requirements and assess the facility's conditions and operations.
Findings
The inspection found the facility to be clean, well-maintained, and in compliance with all applicable regulations. No deficiencies or citations were observed during the visit.
Report Facts
Resident bedrooms: 56
Resident bathrooms: 56
Common bathrooms: 12
Fire extinguishers: 39
Carbon monoxide detectors: 10
Smoke detectors: 107
First aid kits: 10
Resident medication records reviewed: 6
Resident service records reviewed: 6
Staff files reviewed: 6
Temperature: 73
Commercial General Liability coverage: 1000000
Commercial General Liability coverage: 3000000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kenia Sanchez Padilla | Administrator | Facility administrator who escorted the Licensing Program Analyst and was involved in the inspection |
| Jose Calderon | Licensing Program Analyst | Conducted the inspection visit |
| Eva M Alvarez | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 91
Deficiencies: 0
Sep 25, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not provide meals to a resident in care.
Findings
The investigation included interviews with residents, staff, and a witness, as well as a review of facility documents and observation of the kitchen. The allegation was found to be unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint alleged that staff did not provide meals to a resident in care. The allegation was unsubstantiated after investigation, with residents and staff denying the claim and ample food supply observed.
Report Facts
Residents interviewed: 5
Staff interviewed: 3
Witnesses interviewed: 1
Boxed breakfasts observed: 5
Estimated Days of Completion: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mario Leon | Licensing Program Analyst | Conducted the complaint investigation |
| Kenia Sanchez Padilla | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 91
Deficiencies: 0
Mar 11, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 09/02/2021 regarding resident care and facility practices at Regency Palms Long Beach.
Findings
The investigation found all allegations, including neglect, improper restraint, failure to safeguard personal belongings, restriction of resident movement, improper assistance with transfers and ADLs, and resident threats, to be unsubstantiated based on evidence, interviews, and record reviews.
Complaint Details
The complaint investigation addressed eight allegations involving Resident #1 and Resident #2, including fractured hip, multiple falls, improper restraint, safeguarding of belongings, restriction from leaving with family, improper assistance with transfers and ADLs, and resident threatening a visitor. All allegations were found to be unsubstantiated after review of medical records, interviews with staff, residents, witnesses, and conservators, and examination of facility policies and documentation.
Report Facts
Facility Capacity: 91
Resident Census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernand Dabuet | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Carla Mariano | Administrator | Facility administrator involved in the investigation |
| Janae Hammond | Licensing Program Manager | Oversaw the licensing program and signed the report |
| Fabiola Marciano | Care Coordinator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 91
Deficiencies: 0
Feb 13, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations that facility personnel were insufficient in numbers at all times to prevent residents from falling, answer resident call buttons timely, meet resident needs for incontinence care, and meet resident needs for showering.
Findings
The investigation found no preponderance of evidence to substantiate the allegations regarding staffing insufficiencies related to resident falls, call button response, incontinence care, and showering needs. Staff interviews and roster reviews supported adequate staffing ratios and care provision.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included insufficient staffing to prevent falls, answer call buttons timely, meet incontinence care needs, and meet showering needs. Interviews with staff and review of rosters supported staffing adequacy. Attempts to interview residents were limited due to mental health issues. The anonymous complainant could not be interviewed.
Report Facts
Resident to staff ratio: 8
Capacity: 91
Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Calderon | Licensing Program Analyst | Conducted the complaint investigation. |
| Carla Mariano | Administrator | Facility administrator named in report header. |
Inspection Report
Annual Inspection
Census: 52
Capacity: 91
Deficiencies: 0
Dec 21, 2022
Visit Reason
An unannounced annual required visit was conducted with a primary focus on Infection Control measures.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. No deficiencies were cited during this inspection visit.
Report Facts
Fire extinguishers: 39
Resident room smoke detectors: 39
Fire drill date: Dec 13, 2022
Emergency pull cord response time: 42
Hot water temperature: 107.9
Hot water temperature: 118.2
Hot water temperature: 117
Facility temperature: 73.1
PPE supply: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Mariano | Administrator | Met with Licensing Program Analyst during the inspection and named in the report. |
| Mario Leon | Licensing Program Analyst | Conducted the inspection visit. |
| Ulysses Coronel | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 91
Deficiencies: 2
Nov 5, 2021
Visit Reason
The inspection visit was an unannounced complaint investigation initiated due to allegations including a resident sustaining an injury from an unwitnessed fall, inaccessible resident call buttons, and facility short staffing.
Findings
The investigation substantiated that a resident sustained an injury due to an unwitnessed fall and that resident call buttons were not accessible due to missing pull cords on 11 call box stations. The allegation of short staffing was unsubstantiated based on staff and resident interviews and document reviews.
Complaint Details
The complaint investigation was triggered by allegations that a resident sustained an injury due to an unwitnessed fall, resident call buttons were not accessible, and the facility was short staffed. The fall injury and inaccessible call button allegations were substantiated, while the short staffing allegation was unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The licensee failed to ensure the safety of residents as 11 facility resident room call box stations did not have pull cords, posing a potential health risk. | Type A |
| Failure to provide residents with safe, healthful, and comfortable accommodations related to personal rights. | Type B |
Report Facts
Number of residents present during inspection: 52
Total licensed capacity: 91
Number of call box stations without pull cords: 11
Plan of Correction due date: Nov 30, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Mariano | Administrator | Facility administrator involved in the investigation and exit interviews |
| Susan Campos | Licensing Program Analyst | Evaluator who conducted the complaint investigation |
| Michael Cava | Licensing Program Manager | Manager overseeing the licensing program and investigation |
Inspection Report
Annual Inspection
Census: 52
Capacity: 91
Deficiencies: 0
Oct 7, 2021
Visit Reason
An unannounced annual required visit was conducted with a primary focus on Infection Control measures using the new CARE Inspection Tool.
Findings
The facility was found to be sanitary, appropriately furnished, and compliant with infection control practices. No deficiencies were cited during this inspection visit.
Report Facts
Fire extinguishers checked: 39
Resident room smoke detectors checked: 39
Resident rooms inspected for hot water temperature: 14
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Mariano | Administrator | Facility Administrator who allowed entry and participated in the visit. |
| Susan Campos | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Ngozi Nwaokoro | Licensing Program Analyst | Conducted the inspection. |
| Michael Cava | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 91
Deficiencies: 1
Apr 16, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 11/24/2020 regarding insufficient staffing leading to residents not being changed in a timely manner and other related concerns.
Findings
The investigation found sufficient evidence to substantiate the allegation that residents were not changed in a timely manner during the night shift, posing a potential health risk. However, allegations that residents were not receiving showers, staff were not properly trained, staff were rough with residents, and staff were not meeting residents' needs due to insufficient staffing were not substantiated.
Complaint Details
The complaint investigation was substantiated for the allegation that residents were not changed in a timely manner during the night shift. Other allegations including insufficient staffing affecting showers, training, resident care, and rough treatment were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that residents were incontinent changed during the night shift, posing a potential health risk. | Type B |
Report Facts
Capacity: 91
Census: 58
Staff interviewed: 9
Residents interviewed: 5
Deficiency count: 1
Plan of Correction Due Date: May 3, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Mariano | Administrator | Facility administrator involved in investigation and telephonic interviews |
| Susan Campos | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Eva M Alvarez | Licensing Program Manager | Manager overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 91
Deficiencies: 2
Mar 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address allegations received on 2020-07-29 regarding staff not meeting residents' needs, not safeguarding residents' personal belongings, and staff not properly trained.
Findings
The investigation substantiated that staff did not safeguard residents' personal belongings and that staff were not meeting residents' needs, including grooming and laundry issues. The allegation that staff were not properly trained was found to be unsubstantiated based on interviews and document reviews.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not safeguard residents' personal belongings and that staff were not meeting residents' needs. The allegation that staff were not properly trained was unsubstantiated. The investigation included interviews with 8 staff members, 8 residents, and a family member, document reviews, and telephonic/video inspections.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure basic laundry service (washing, drying, and ironing of personal clothing) was properly provided, resulting in damage to resident's clothing. | Type B |
| Failure to provide care, supervision, and services that meet individual resident needs, including grooming and fingernail trimming. | Type B |
Report Facts
Staff interviewed: 8
Residents interviewed: 8
Resident census: 51
Facility capacity: 91
Residents with untrimmed fingernails observed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Campos | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva M Alvarez | Licensing Program Manager | Oversaw the complaint investigation |
| Carla Mariano | Administrator | Facility administrator involved in telephonic exit interviews and document submissions |
| Christine Tomlinson | Administrator | Named as facility administrator in report header |
| S1 | Facility staff member interviewed regarding training, laundry procedures, and resident care |
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