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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191200037
Report Date: 10/13/2026
Date Signed: 10/13/2026 09:49:42 AM

Document Has Been Signed on 10/13/2026 09:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:REGENCY PARK OAK KNOLLFACILITY NUMBER:
191200037
ADMINISTRATOR/
DIRECTOR:		ANABELLE ARGENALFACILITY TYPE:
740
ADDRESS:255 SOUTH OAK KNOLLTELEPHONE:
(626) 578-1551
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 206CENSUS: 100DATE:
10/13/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Jacqueline Hernandez, Business Office ManagerTIME VISIT/
INSPECTION COMPLETED:
09:58 AM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced case management visit as a follow up to the Special Incident Report (SIR) dated 11/11/2025. LPA met with the Business Office Manager, Jaqueline Hernandez and LPA explained the purpose of the visit.

LPA reviewed the Special Incident Report (SIR) dated 11/11/2025 that indicated Resident #1 (R1) was found with swelling on the upper left leg on 11/05/2025. Facility conducted an internal investigation, and it was determined that one caregiver did not follow procedure with transfers. LPA reviewed facility notes which indicated that on 11/03/2025 Staff #1 (S1) transferred R1 from their wheelchair to their bed with a “bear hug transfer” and heard a pop sound. When S1 was questioned if they were aware that R1 requires a two-person assist, S1 indicated that he was aware but that he trusted himself. X-ray was conducted on 11/07/2025 and the X-ray results were provided on 11/10/2025 that diagnosed R1 with a moderate displaced proximal femur fracture with decreased bone mineralization. The facility terminated S1 on 11/11/2025 due to improper/unsafe safety with transfer. LPA interviewed the Executive Director that confirmed that R1 was provided a one person assist from S1 when R1 should have been provided a two person assist.

Immediate $500 Civil Penalty is being issued during today’s visit due to facility staff not properly transferring a resident in care resulting in an injury.



Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the 809D. Exit interview held and a copy of the report along with appeal rights were provided to the Business Office Manager, Jacqueline Hernandez.
David Sicairos
Daniel Konishi
DATE: 10/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

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

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

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

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

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

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

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

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

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

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/13/2026 09:49 AM - It Cannot Be Edited


Created By: Daniel Konishi On 10/13/2026 at 09:32 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY PARK OAK KNOLL
FACILITY NUMBER: 191200037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2026
Section Cited
CCR
87411(a)

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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
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Executive Director will submit a plan to the LPA by the POC due date to ensure that the facility will conduct proper and safe transfer two person assists. Executive Director will conduct and schedule a training on safe transfer and two-person assists and send the training materials and sign-up sheets to the LPA by 10/27/2026.
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Based on record review and staff interview, the facility was not in compliance as a Special Incident Report dated 11/11/2025, Resident #1 (R1) was improperly transferred by one person assist from Staff #1 (S1) since R1 required two person assist. This poses an immediate health, safety, and/or personal rights risk to the clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2026


LIC809 (FAS) - (06/04)
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