191592479-8-8-2024-28-AS-BTAO-D7XV8X-20240808161327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592479
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:14:14 PM

Document Has Been Signed on 08/08/2024 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	ATRIA COVINA		FACILITY NUMBER:	191592479
ADMINISTRATOR:	ALONDRA FUENTES		FACILITY TYPE:	740
ADDRESS:	825 W SAN BERNARDINO RD		TELEPHONE:	(626) 967-9621
CITY:	COVINA	STATE: CA	ZIP CODE:	91722
CAPACITY:	90	CENSUS: 62	DATE:	08/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Brooke Lamotte, Resident Service Director		TIME COMPLETED:	02:30 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 Brooke Lamotte, Resident Service Director and the purpose of today's visit was discussed. 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. The facility has eight (8) hospice waiver on file, six (6) residents are on hospice, and five (5) residents with dementia. Annual fees are current. Administrator certificate is current and expiring on 8/14/25. This annual inspection consisted of applying CARE tools; conducting physical plant; reviewing food supply, staff and residents files, and medication; and interviewing of staff/residents. The facility is a two-story building with 63 resident rooms. 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. Resident rooms consisted of a bedroom, bathroom and closet. Residents' rooms and bathrooms were inspected and in compliance. Hot water temperature was measured in a range from 106.7 to 120.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Sufficient supply of perishable and nonperishable foods were observed. (-continued on 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: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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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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: 08/08/2024

NARRATIVE

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Smoke detectors and carbon monoxide detectors in residents' rooms are operable. Smoke detectors in the common areas are hard wired and monitored by a fire alarm company which it's last service was on 6/12/24. The fire extinguishers were fully charged. Elevator at the facility is operable.

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 7/7/24. LPA checked the signal systems in resident rooms and found system to be operable and staff responded to residents in a range from 7 to 10 minutes.

No deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6. An exit interview was conducted. This report was discussed with Administrator and report LIC 809s were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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