198603428-3-25-2025-28-AS-RORN-DFBQU6-20250401122814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603428
Report Date: 03/25/2025
Date Signed: 03/25/2025 01:19:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2025 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250225160630

FACILITY NAME:	REGENCY GRAND AT WEST COVINA		FACILITY NUMBER:	198603428
ADMINISTRATOR:	MIMS-BURRIS, MARY		FACILITY TYPE:	740
ADDRESS:	150 SOUTH GRAND AVENUE		TELEPHONE:	(626) 332-3344
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	160	CENSUS: 100	DATE:	03/25/2025
		UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Mary Mims Burris - Executive Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff speaks inappropriately to resident in care
Facility is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent compliant investigation visit regarding the above allegations. LPA met with Mary Mims Burris Executive Director and explained the reason for the visit.

The investigation consisted of the following: On 3/6/25 LPA Deleon and LPM Fierros conducted an unannounced complaint investigation visit and toured the facility, obtained a copy of the staff and resident roster, resident #1's face sheet, admission agreement, and medical assessment, repair invoices from February to March 2025. LPA conducted interviews with administrator and staff 1 (S1) and resident #1(R1) . On 3/25/25 LPA Flores conduced interviews with 9 residents and 7 staff, requested work orders, LPA toured room #354 and #206 and delivered findings.

The investigation revealed the following: Regarding allegation: Staff speak inappropriately to resident in care. It is alleged staff is harassing resident for disrepairs in the room. (CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250225160630

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY GRAND AT WEST COVINA	FACILITY NUMBER: 198603428
	VISIT DATE: 03/25/2025

NARRATIVE

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Interviews with residents revealed 9 out of 9 residents interview stated staff are respectful, calm when addressing residents, and helpful around the facility. One resident stated to have felt blamed over an incident with the physical plant of the facility. Interviews with staff revealed 7 out of 7 staff stated staff are respectful when speaking to the residents, communication with residents is professional, and they always maintain a calm manner. Administrator stated that upon an incident with that resulted in a lot of damage from a resident’s shower, administrator questioned the resident how the handle broke. However, Administrator did not blame the resident of using tools to break the shower handle. Therefore, although the resident felt administrator was blaming the resident for breaking the shower handle there is not sufficient evidence or witnesses to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Facility is in disrepair. It is alleged bathroom handle broke on 2/14/25 and resident reported it many times prior to that, which has resulted in resident not being able to shower in own bathroom. Interviews with residents revealed 8 out of 9 residents have either not experience anything in their rooms to be in disrepair or facility’s staff have successfully repair reported items in a timely manner. 1 out of 9 residents stated to have had difficulties with shower handle and on one occasion the shower handles broke, with water gashing out. Per R1 since the shower in their room was out of order, facility staff provided assistance in a vacant room to use the shower while the shower was repaired. Interviews with staff revealed when an item is reported to be repaired in the residents’ room, maintenance is quick to respond and finish repairs. Interview with maintenance assistant revealed, staff responded three times prior the incident in which the water gashed and replace parts inside the shower handle or shower handle. Per maintenance staff the shower handles are all uniform in each room and replacement supplies are the same as well. They also stated that the mechanism of the shower handle must be treated in a gentle manner without excessive turns or turning all the way as the screw inside can break off. Which is what happened in room #354’s shower handles each time it was replaced. Per maintenance assistance, the three times the shower handle was repaired, staff explained to the resident how to use the shower handles to prevent them from breaking again. Administrator explained that the last time the shower handles broke, the shower was out of order for a couple of weeks as they had to replace the dry wall and provided a similar mechanism to the shower handle which has been better for the resident. During facility's tour conducted on 3/6/25 and 3/25/25 facility was observed in good repair.
(CONTINUED ON LIC 9099C)

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250225160630

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY GRAND AT WEST COVINA	FACILITY NUMBER: 198603428
	VISIT DATE: 03/25/2025

NARRATIVE

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Documents reviewed revealed maintenance staff responded to the following work order dates in room #354; On 12/30/24 staff greased the area of shower handle. On 1/15/25 staff removed and replaced the shower handles. On 1/19/25 shower cartridge was replaced. On 2/1/25 shower cartridge was replaced. Incident report dated 3/7/25 notes incident occurred on 2/14/25 in which “shower stem broke into the wall.” Although the shower handles broke more than once, facility staff replaced it each time and assisted R1 with guidance to use the handles properly. Therefore, this allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Mary Mims Burris and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025

LIC9099 (FAS) - (06/04)

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