198603428-4-24-2025-28-AS-DKOI-DG2VVR-20250424164646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603428
Report Date: 04/24/2025
Date Signed: 04/24/2025 04:47:08 PM

Document Has Been Signed on 04/24/2025 04:47 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	REGENCY GRAND AT WEST COVINA		FACILITY NUMBER:	198603428
ADMINISTRATOR/ DIRECTOR:	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: 103	DATE:	04/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:25 PM
MET WITH:	Mary Mims-Burris, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:55 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted the Unannounced required annual inspection. LPA arrived unannounced and met with the Executive Director, Mary Mims-Burris and assisted with the visit. 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. Currently, the facility has 11 hospice waiver residents and 3 home health residents.

On today's date, LPA inspected the eight (8) domains include: Infection Control, Operational Requirement, Physical Plant Environmental Safety, Resident Right-Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness.

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

Operational Requirement: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 15 residents is approved. A fire clearance approved for 49 ambulatory and 111 non-ambulatory with no bedridden residents. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($2,000,000) is in place.

Physical Plant and Environmental Safety: The facility is a three-story building. The first floor includes memory care unit and assisted living resident's rooms, main lobby, administrative office, Bristol, wellness director office, two activity rooms, resident coordinator office, assistant director office, Chart room, Library, Multi-purpose room, resident mailbox, community laundry room, dining room and facility kitchen. The 2nd floor includes laundry room, activity room, unisex bathroom and assisted living residents' rooms.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY GRAND AT WEST COVINA	FACILITY NUMBER: 198603428
	VISIT DATE: 04/24/2025

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Physical Plant and Environmental Safety [Cont.]: The 3rd floor include laundry room, activity room, exercise room and unisex bathroom and assisted living residents' rooms. During the facility tour, LPA inspected Room #106, #108. #122, #123, #218, #220, #221, #320 and #321, #335, #351 and they all have sufficient lighting and required furniture in the residents’ rooms. For the resident bathrooms, they are clean, sanitary and in a good working condition. All the residents’ bathrooms have the required Nonskid mat and grab bar in the bathtub and toilet. LPA tested the hot water temperature and they are between 116.8-degrees F and 123.4-degrees F (Rm#106 was 122.1 degrees F, Rm#108 was 123.2 degrees F, Rm#218 was 123.4 degrees F, Rm#220 was 121.8 degrees F, Rm#335 was 122.8 degrees F, and Rm#351 was 121.4 degrees F) which are not within the Tittle 22 regulation. The carbon monoxide detector is located in the laundry room and it's working properly. LPA reviewed the annual fire inspection and testing report via the state fire marshal and everything is working well. All the cleaning solutions and chemicals are locked in the janitor room and inaccessible to the residents. Facility has a telephone service on the premises. The backyard / rear grounds of the facility is well landscaped and the passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash can or containers have the covered lids.

Resident's Right Information: LPA observed the required posters posted nearby the residents' mailbox which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted and LPA reviewed the calendar for both Assisted Living and Memory Care Unit. The facility does have an active Resident Council.

Food Services: Currently the facility has about 3 residents in the Assisted Living and 2 residents in the Memory Care Unit are required to have modified diet. The facility has ample supply for two days perishable and seven days non-perishable food supply. The facility kitchen is clean and kept free of litter, rodents and insects. All food in the facility are stored properly.

[Continue in LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY GRAND AT WEST COVINA	FACILITY NUMBER: 198603428
	VISIT DATE: 04/24/2025

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Incidental Medical and Dental: LPA inspected twelve (12) residents' medication which include nine (9) from Assisted Living and three (3) from Memory Care Unit and they are centrally stored and locked in the medication room and they seemed accurate and updated and also contained 30 days’ supply of medication. The facility would also provide medical and dental transportation if needed

Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and it’s updated on 01/08/2025. The last fire drill was conducted on 03/11/2025. The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training.

Due to time restraint and LPA was not able to complete the full inspection tool and interview residents and staff and LPA will come back at another time to complete.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to the Executive Director, Mary Mims-Burris.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/24/2025 04:47 PM - It Cannot Be Edited

Created By: Daniel Konishi On 04/24/2025 at 04:29 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA tested hot water temperature in bathrooms in Rm#106 was 122.1 degrees F, Rm#108 was 123.2 degrees F, Rm#218 was 123.4 degrees F, Rm#220 was 121.8 degrees F, Rm#335 was 122.8 degrees F, and Rm#351 was 121.4 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2025
	Plan of Correction
1 2 3 4	Licensee shall immediately adjust water temperature. Licensee to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105 degree F and 120 degrees F. Licensee will provide a copy of the log to the department once water temperature falls within Title 22 guidelines.

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.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

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