<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191592479
Report Date: 09/05/2023
Date Signed: 09/05/2023 03:53:52 PM


Document Has Been Signed on 09/05/2023 03:53 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: 61DATE:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Alondra Fuentes, Administrator TIME COMPLETED:
04:15 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 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.

During the visit, the new inspection CARE tool was used; a tour of the facility was conducted; food supply was reviewed; staff/residents files were reviewed; staff/residents interviews were conducted; and medications were reviewed.

The facility is a two-story building with 63 resident rooms. LPA toured resident rooms #113, #104, #122, #233, #202 and #217. 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 112.5 to 115.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed.

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. (-continued in LIC 809 C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023
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: 09/05/2023
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 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, named Johnson Controls and last services is on 4/23/2023. The facility has a total of ten (10) fire extinguishers. They are fully charged and last services was conducted on Aug 2023. 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 8/27/2023. LPA checked the signal systems in resident rooms and found system to be operable and staff responded to residents in a range from 2 to 9 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 are provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2