191592479-8-26-2022-28-AS-BTAO-CHNVCR-20220826161935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592479
Report Date: 08/26/2022
Date Signed: 08/26/2022 04:19:43 PM

Document Has Been Signed on 08/26/2022 04:19 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: 54	DATE:	08/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Alondra Fuentes, Administrator		TIME COMPLETED:	04:45 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 Alondra Fuentes, Administrator who assisted with the 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 on file. Two (2) residents are on hospice. Facility has five (5) dementia residents. Annual fees are current. Administrator certificate is current, expires on 08/14/2023. 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 with 63 resident rooms. LPA toured resident rooms #105, #123, #128, #227, #231 and #236. 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 measured in a range from 106.5 to 115.9 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. (-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: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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: 08/26/2022

NARRATIVE

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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 were observed.

Smoke detectors and carbon monoxide detectors in residents' rooms are operable. Smoke detectors in the hallway and common areas are hard wired. They are monitored by a fire alarm company. The facility has a total of ten (10) fire extinguishers. They are 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 7/12/2022. LPA checked the signal systems in resident rooms and found system to be operable and staff responded to residents in a range from 3 to 7 minutes.

Deficiencies were cited per California Code of Regulations, Title 22, in LIC 809D.

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: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2022 04:19 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(j)

87705 Care of Persons with Dementia. (j) The licensee shall have an auditory device or other staff alert feature to monitor exits This requirement is not met as evidenced by: Auditory device at the exit to the parking lot is not operable.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2022
	Plan of Correction
1 2 3 4	Licensee will repair the auditory alarm device at the exit to the parking lot by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC809 (FAS) - (06/04)

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