191592479-8-20-2021-28-AS-BTAO-C63W27-20210820165353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592479
Report Date: 08/20/2021
Date Signed: 08/20/2021 04:54:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ATRIA COVINA		FACILITY NUMBER:	191592479
ADMINISTRATOR:	SUBASHSANI KUMAR		FACILITY TYPE:	740
ADDRESS:	825 W SAN BERNARDINO RD		TELEPHONE:	(626) 967-9621
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY:	90	CENSUS: 54	DATE:	08/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Irina Sarkisyan, Executive Director and Milred Pascual, Resident Services Director		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Executive Director, Irina Sarkisyan and Resident Services Director, Mildred Pascual, both assisted with visit. The facility has a capacity of 90 residents. It is licensed to serve elderly residents age 60 and above, approved for fifty-six (56) non ambulatory residents. The facility has eight (8) Hospice Waiver for on file. Four (4) residents are on hospice. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is a two-story building and 63 resident rooms. Resident rooms consisted of a bedroom, bathroom and closet. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 105.5 to 113.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. The facility consists of seven (7) office rooms, reception area, beauty salon, med room, library, activity room, dining room, kitchen, two (2) laundry rooms, two (2) housekeeping storage rooms, staff lounge, and courtyard. Four (4) public restrooms are available which are clean and operational. Sufficient supply of perishable and nonperishable foods. Smoke detectors and carbon monoxide detectors are operable. (-continued in LIC 809 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ATRIA COVINA	FACILITY NUMBER: 191592479
	VISIT DATE: 08/20/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Smoke detectors in the hallway and common areas are hard wired. They are monitored by a fire alarm company. The facility has total of ten (10) fire extinguishers. They are fully charged and last service was on December 20, 2020. First aid kit is fully stocked with a manual. All mandated documents and signages are posted in common areas. The outdoor activity area is free of visible hazards and debris. There is shaded patio and garden areas with ample seating. Medications are centrally stored and locked. Resident records inspected are current. Fire/ Emergency drill conducted on 7/26/2021. LPA checked the signal systems in resident rooms and found system to be operable and staff responded to resident rooms within five minutes.

No deficiencies cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2