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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603428
Report Date: 04/29/2025
Date Signed: 04/29/2025 04:40:16 PM

Document Has Been Signed on 04/29/2025 04:40 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 COVINAFACILITY NUMBER:
198603428
ADMINISTRATOR/
DIRECTOR:		MIMS-BURRIS, MARYFACILITY TYPE:
740
ADDRESS:150 SOUTH GRAND AVENUETELEPHONE:
(626) 332-3344
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 160CENSUS: 103DATE:
04/29/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Mary Mims-Burris, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:50 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 6 home health residents.

The initial annual visit was conducted on 04/24/2025. During the initial visit the following eight (8) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Operational Requirement, Physical Plant Environmental Safety, Resident Right-Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness.

During today’s annual visit, the following four (4) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Staffing, Personnel Records-Training, Resident Records-Personnel Reports, Resident with Special Health Needs.

Staffing: Facility has sufficient staffing for care and supervision to the residents.

Personnel Records-Training: All the staff in the facility are over 18 years old and fingerprint cleared with the facility. The administrator is Mary Mims-Burris and her administrator certificate expires on 10/02/2025. LPA reviewed all nine (9) staff files and they all have the required documents in file which included: health screening, TB test result, employee rights, required training hours and updated first aid certificate.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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: 04/29/2025
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Resident Records-Incident Reports: LPA inspected eleven (11) residents files which include eight (8) residents files from Assisted Living and three (3) residents files from Memory Care and they all have the required documents in file which included: admission agreements, Physician's Reports, Updated Needs and Service Plan, Pre-appraisal, TB clearance, Physician’s Orders, Personal Rights, and medication records.

Resident with Special Health Needs: No residents in the facility with prohibited health conditions. No residents in the facility with postural supports. Currently there are eleven (11) residents on hospices and six (6) residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. There are interior and exterior space available on the facility premises to permit residents with dementia to wander freely and safely.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit Interview conducted and a copy of the report 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: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
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