198603428-3-22-2023-28-AS-RORN-CTFU92-20230705152225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603428
Report Date: 03/21/2023
Date Signed: 03/22/2023 03:56:19 PM

Substantiated

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
03/17/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230317082628

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:	03/21/2023
		UNANNOUNCED	TIME BEGAN:	07:35 AM
MET WITH:	Nichole Greene		TIME COMPLETED:	08:15 AM

ALLEGATION(S):

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Facility has cockroaches

INVESTIGATION FINDINGS:

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This report serves as an addendum and supersedes the complaint investigation report created on 3/20/2023. This addendum is written to provide the clarification on LIC 9099C and LIC9099D and does not change the complaint investigation report findings recorded on 3/20/2023.

Licensing Program Analyst (LPA) Christine Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation and to establish the validity of the complaint. LPA met with Receptionist Debbie Golden who allowed entry into the facility and was later met by Administrator Nichole Greene arrived and assisted with the visit.

The investigation consisted of the following: LPA toured the kitchen and interviewed the administrator, six (6) staff and nine (9) residents (R1-R9) in the facility and also obtained resident and staff roster, the copy of monthly services bill from Wipe out Pest Control and services notification dated on 10/12/22, 11/7/22, 01/24/23, 2/22/23 and 03/06/23. (See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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-20230317082628

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: 03/21/2023

NARRATIVE

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The investigation revealed of the following: Allegation "Facility has cockroaches" LPA interviewed nine (9) residents and all denied the allegation and reported that facility is clean and they never seen any cockroaches in their rooms or dining room. LPA interviewed six (6) staff and five out of six staff reported that they did see cockroaches in the kitchen and the last time they saw was about a week and two weeks ago. The staff reported it's been getting better as the pest control did come and put the trap under the kitchen compartment but they would like to fix the cockroaches issues completely.

Based on LPA's records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

An exit interview was conducted with Administrator Nichole Greene and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230317082628

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/27/2023 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b)The following food service requirements shall apply:(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. The requirement was not met as evidenced by:	1 2 3 4 5 6 7	The administrator will ensure the kitchen area shall be kept clean and free of rodents, litter,vermin and insects and the administrator will discuss with the pest control and send the copy the pest control services plan to LPA by POC due date.
	8 9 10 11 12 13 14	LPA's interviews, five out of six staff reported they saw cockroaches in the kitchen, although its getting better as the pest control already put the trap under the kitchen compartment which posed a potential risk for residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 03/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC9099 (FAS) - (06/04)

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