198603428-3-14-2024-28-AS-CWOG-D3CVBQ-20240314161755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603428
Report Date: 03/14/2024
Date Signed: 03/14/2024 04:58:14 PM

Document Has Been Signed on 03/14/2024 04:58 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
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: 100	DATE:	03/14/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Mary Mims-Burris		TIME COMPLETED:	04:30 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 Analyst (LPA) Christine Wong conducted an Annual/Required visit by using the Compliance And Regulatory Enforcement (CARE) Tools on 03/12/24 but due to time restrains and LPAs Christine Wong and Daniel Konishi has returned on today's date 03/14/24 to finish the remaining Ten ( 10) domains. LPA met with Receptionist Debbie Golden who allowed entry into the facility and Shortly after, the Administrator Mary Mims-Burris arrived and assisted with the visit On today's date, LPA inspected the Nine (9) domains include: Infection Control, Operational Requirement, Staffing, Personnel Records-Training, Resident Right-Information, Planned Activities, Incidental Medical and Dental, Resident Records and Incident reports, Disaster Preparedness and Residents with Special Health Needs. 1. 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. 2. 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 bed ridden 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. 3. Staffing- Facility has sufficient staffing for care and supervision to the residents. 4. 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 expired on 10/2/23 and currently is pending application in our internal CCL system since 10/3/23. LPA reviewed all 10 staff files and they all have the required documents in file which included: health screening, TB test result, required training hours and updated first aid certificate.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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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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: 03/14/2024

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5. 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.

6. 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.

7. Incidental Medical and Dental: LPA inspected eight (8) residents' medication which include (3) from Assisted Living and (5) from Memory Care Unit and they are centrally stored and locked in the medication room and they are seemed accurate and updated and also contained 30 days supply of medication. The facility would also provide medical and dental transportation if needed.

8. Resident Records-Incident Reports: LPA inspected 10 residents files 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, medical consent, and medication records.

9. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and its updated on 03/2024. The last fire drill was conducted on 01/18/24 The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training.

10. Resident with Special Health Needs. No residents in the facility with prohibited health condition. Currently there are 11 resident on hospices and two residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice.

Exit Interview conducted and a copy of the report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

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