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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592479
Report Date: 05/10/2024
Date Signed: 05/10/2024 10:55:35 AM


Document Has Been Signed on 05/10/2024 10:55 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ATRIA COVINAFACILITY NUMBER:
191592479
ADMINISTRATOR:ALONDRA FUENTESFACILITY TYPE:
740
ADDRESS:825 W SAN BERNARDINO RDTELEPHONE:
(626) 967-9621
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:90CENSUS: 61DATE:
05/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Alondra Fuentes, administrator, and
Irina Sarkisyan, Community Business Director		TIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Tao and Reyes conducted an unannounced Case Management- Incident visit in response to Client (C1’s) Incident Report, dated 04/26/24. The facility has a capacity of 90 residents and licensed to serve elderly residents age 60 and above. The facility is approved for fifty-six (56) non-ambulatory residents. LPAs explained the purpose of today's visit to Irina Sarkisyan, Community Business Director and administrator who assisted with this visit.

During today's visit LPA toured the facility, interviewed Administrator, staff, resident#1 (R1) and reviewed R1's file. The incident report stated R1 said to the administrator that staff grabbed and twisted resident#1’s right arm. LPA interviewed Administrator/staff revealed that the facility investigated this incident and the finding was unfound. Per interview of R1, resident seem unable to recall the incident. Staff and hospice nurse were monitoring the resident. LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats.

LPA obtained copies of the following documents:
· Staff roster/Resident roster
· R1’s Identification/Emergency Contact Information (facesheet)/ Hospice Document
· Needs and service plan/Unusual Incident Report/In-service training
· Admission Agreement Attachment C (Personal Rights)
· Physician Report /Pre appraisal / Admission Agreement

No deficiencies were observed and cited during this visit. Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
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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