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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592479
Report Date: 08/30/2024
Date Signed: 08/30/2024 05:01:37 PM


Document Has Been Signed on 08/30/2024 05:01 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 COVINAFACILITY NUMBER:
191592479
ADMINISTRATOR:ALONDRA FUENTESFACILITY TYPE:
740
ADDRESS:825 W SAN BERNARDINO RDTELEPHONE:
(626) 967-9621
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:90CENSUS: 60DATE:
08/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Irina Sarkisyan, Community Business DirectorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced Case Management- Incident visit in response to resident#1 (R1) Incident Report, dated 08/21/24. 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. LPA explained the purpose of today's visit to Irina Sarkisyan, Community Business Director 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 reported that staff took R1 out to the courtyard at 7am for 10 mins. R1 was upset and stated staff hit R1. 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. Police came and found it unfound. Case#24-18510. 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 / Resident roster
· R1’s Identification/Emergency Contact Information (facesheet)
· Unusual Incident Report
· Physician Report
· In-service training

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: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
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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