198603428-4-8-2021-28-AS-KLOG-BZVTXL-20210408150718

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603428
Report Date: 04/08/2021
Date Signed: 04/08/2021 03:07:41 PM

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:	REGENCY GRAND AT WEST COVINA		FACILITY NUMBER:	198603428
ADMINISTRATOR:	GREENE, NICHOLE		FACILITY TYPE:	740
ADDRESS:	150 SOUTH GRAND AVENUE		TELEPHONE:	(626) 332-3344
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	160	CENSUS: 82	DATE:	04/08/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Nichole Greene (Administrator)		TIME COMPLETED:	03:00 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) Kruz Long conducted an announced Pre-licensing inspection. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today's inspection was conducted via Microsoft Team (Video Conference) with Nichole Greene (Administrator). An application was received for initial License #198603428, Residential Care Facility for the Elderly. AGE RANGE 60 AND OVER. APPROVED FOR 49 AMBULATORY AND 111 NON-AMBULATORY, INCLUDING THOSE IN MEMORY CARE UNIT WITH DELAYED EGRESS. HOSPICE WAIVER APPROVED FOR 15 RESIDENTS. The facility is a 3 story building consisting the following: First floor contains common areas, medication rooms, multipurpose room, activity room, lobby, bistro, parlor, library, dining room, kitchen, offices, memory care and assisted living apartments. Second floor contains a laundry room, parlor, activity office, storage room, office and assisted living apartments. Third floor contains a laundry room, billiards room, storage room, assisted living apartment. During today's inspection, LPA observed the following: · Facility is clean, sanitary and in good repair. · Bedrooms are large enough to accommodate furniture. · Each apartment has its own bathroom which have working toilets, wash basins, showers, grab bars and non-skid mat/floors. · Each resident bedroom has its alert button. · Hygiene supplies are available for resident use. · Emergency Phone Numbers, Exit Plan & Menu are posted & readily available for review. Continue to LIC809C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

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: REGENCY GRAND AT WEST COVINA	FACILITY NUMBER: 198603428
	VISIT DATE: 04/08/2021

NARRATIVE

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· Fire Extinguishers are fully charged.
· Smoke Detectors and Carbon monoxide detectors are operational.
· Water Temperature measured within Title 22 guidelines in all floors.
· Kitchen contain the necessary food supplies.
· Dishes, cups and flat ware are in good repair.
· First aid kits are located in the medication rooms, front office and kitchen.
· There are no Pool/Jacuzzi on the premises.
· Medications are centrally stored in the medication room.
· Chemicals agents are safely secured and inaccessible to residents.
· Cameras are located in the common areas.
· There are outdoor shaded areas.
· Passageways, stairways, walkways, driveway and steps are free of debris and obstructions.

Fire Safety Clearance was granted on 04/01/21.

Component III: Waved: Licensee is currently operating under License #292700563 of the same category.

During the pre-licensing inspection, LPA did not observe items which do not comply with applicable laws and regulations.

Tele-inspection was completed and an exit interview was conducted. Copy of this report was emailed to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

LIC809 (FAS) - (06/04)

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