198603428-4-26-2022-28-AS-KLOG-CDUTJR-20220426144646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603428
Report Date: 04/26/2022
Date Signed: 04/26/2022 02:47:31 PM

Document Has Been Signed on 04/26/2022 02:47 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:	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: 98	DATE:	04/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
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 unannounced visit to the facility to conduct an Annual Inspection. Upon arrival, LPA met with Nichole Greene (Administrator) and explained the purpose of the visit. The facility is licensed to serve: 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 which consist 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 (each with a bathroom). Second floor contains a laundry room, parlor, activity office, storage room, office and assisted living apartments (each with a bathroom). Third floor contains a laundry room, billiards room, storage room, assisted living apartment (each with a bathroom). During today's inspection, LPA observed the following: Facilities maintains in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Facility is not operating over capacity or beyond any conditions and limitation on the license. No ammunition or firearms on the premises. Facility maintains a comfortable temperature for residents. All outdoor and indoor passageways are free of obstruction. Hot water temperature measured between 105 degrees F and 120 degrees F in various bathrooms on each floor. The presence of grab bars for each toilet, bathtub and shower used by residents was observed. Bathtub or shower have non-skid mats or strips. Beds have the required linen/supplies which include pillowcase, mattress pads, fitted sheet, blanket and bed spreads. Adequate supply of linens are stored in supply room. Facilities have a signal system that operates from each resident’s living unit. Minimum of one week supply of nonperishable foods and 2 days of perishable foods was observed. 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: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

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: REGENCY GRAND AT WEST COVINA	FACILITY NUMBER: 198603428
	VISIT DATE: 04/26/2022

NARRATIVE

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All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. Smoke and Carbon Monoxide detectors are operable. The facility has sufficient and competent staff to provide the services needed to meet resident needs. Delayed egress devices is not substituted for trained staff in sufficient numbers to meet the needs of all dementia residents and to escort residents who leave the facility. Items that could constitute a danger is stored inaccessible to dementia residents. A first aid kit has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, first aid manual available for staff use but inaccessible for residents. Staff assisting residents with ADLs have required training. Staff has criminal record clearance. Staff responsible for direct care and supervision have current first aid training. Facility have a disaster and mass casualty plan. Employees of CCLD is allowed to enter the facility to conduct inspections. A certified administrator is on the premise for a sufficient number of hours to manage and oversee the business operation. Medications is given per the physician’s directions. Centrally stored medicines is kept in a safe and locked place.

No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to Nichole Greene (Administrator).

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

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