198603428-3-20-2023-28-AS-CWOG-CPYVEU-20230316162254

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603428
Report Date: 03/16/2023
Date Signed: 03/20/2023 11:52:12 AM

Document Has Been Signed on 03/20/2023 11:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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:	03/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nichole Greene		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 Analysts (LPAs) Christine Wong and Erik Zaragoza conducted the required annual inspection. LPAs arrived unannounced and met with Business Office Manager Veronica Roosco. Administrator, Nichole Greene, arrived shortly thereafter to assist. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for 49 ambulatory and 111 non-ambulatory, include those in memory care unit with delayed egress. Hospice Waiver Approved for 15 residents. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting once a day and more often for high touched surfaces. Facility has sufficient PPE supplies and has an Infection Control Plan. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 21 residents in Memory Care Unit and 77 residents in Assisted Living Unit. Currently they have 9 hospice residents reside in the facility. The facility has the sufficient amount for liability insurance covering injury to residents and guests. Physical Plant & Environment Safety: The facility is a three story building. On the first floor, it includes: Reception area, Administrative offices, Chart room, Public Bathroom, Multipurpose room, Library, Dining Area, Kitchen, Resident Mail box, Common area, Lounge, Game room, mini-store, Salon, Commercial Laundry room, Linen Room, Housekeeper Closet, Medication Room, Assisted Living Residents Rooms. For the memory care unit, it includes memory care residents rooms, two staff offices, chart room, dining area, mini-kitchen, activity closet, medication room and Snooze len room. On the second floor, it includes assisted living residents rooms, resident laundry room, activity director office, lounge and a janitor room. On the third floor, it includes: assisted living residents rooms, janitor room, resident laundry room, maintenance director office, storage room, billiards room, gym room and public bathroom. (See LIC 809C for continuation)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/16/2023

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

Facility has a sprinkler system and carbon monoxide detectors located on each resident laundry room. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to residents. There are no firearms or weapons stored at the facility. LPA inspected 10 residents room and they all have required furniture. The bathrooms are clean and sanitary and in a operable working condition except Room 217. The bathroom cabinet door under the sink was broken. The hot water temperature in the all 10 residents bathrooms were measured between the required range of 105-120 degrees F.
Staffing: There is sufficient staffing at the facility. The administrator's (Nichole Green) certificate expires on 08/03/2024 Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-days perishable and a week of non-perishable items. The food are properly stored in the refrigerator.
Incidental Medical & Dental: The medications are centrally stored in the Medication Room and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed all 4 residents' medication and they are being administered as prescribed by the physician.
Disaster Preparedness: The facility has an Updated Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.

The following domains that LPAs were not able to inspect on today's date which include Personnel Record/ Staff Training and Residents with Special Health Care Needs due to time restrain. LPAs also were not able to conduct any staff and residents interview. LPA will come back at another time to complete.

On today's visit: Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the Administrator Nichole Greene

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 03/20/2023 11:52 AM - 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY GRAND AT WEST COVINA	FACILITY NUMBER: 198603428
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(6)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation with the room tour. LPAs observation in Roon#217, the bathroom cabinet door under the sink was broken and posed a potential risk for residents in care.
	POC Due Date: 03/30/2023
	Plan of Correction
1 2 3 4	The administrator will ensure the toilet, handwashing and bathing facilities shall be maintained in a operating condition. The administrator will fix the cabinet door and send the picture to LPA 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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3