198603545-8-2-2022-28-AS-VMAO-CGWSWZ-20220802141510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603545
Report Date: 08/02/2022
Date Signed: 08/02/2022 02:15:18 PM

Document Has Been Signed on 08/02/2022 02:15 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	OAKMONT OF COVINA HILLS		FACILITY NUMBER:	198603545
ADMINISTRATOR:	GUSTIN, PATRICIA		FACILITY TYPE:	740
ADDRESS:	1054 PARK VIEW DRIVE		TELEPHONE:	(626) 885-1800
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	142	CENSUS: 0	DATE:	08/02/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Patricia Gustin- Adminstrator		TIME COMPLETED:	02:20 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's (LPA's) Valeria Maldonado and Jose Villalobos made an announced visit to the facility for the purpose of a pre-licensing inspection. LPA's Maldonado and Villalobos met with Regional Director of Operations Michael Fountain and was met shortly after by Applicant Patricia Gustin. The reason for the inspection was explained. The building is a three story building with a basement, that is licensed to serve residents of ages 60 and over and has a capacity of 142 residents, of which 132 may be non-ambulatory, 8 may bedridden. The facility also has hospice approval for up to 12 residents. During today's visit, an inspection of the physical plant was conducted by LPA's and Patricia Gustin, which consisted of the following: the front lobby, the memory care unit, common areas, resident rooms and private bathrooms, public bathrooms, dining rooms, central restaurant style kitchen, offices, housekeeping closets, activity rooms, bar area, beauty salon, theater room, laundry and linen storage and supply rooms, and medication rooms. The memory care unit is located on the first floor and consists of resident rooms# 101-133, with 8 of the rooms having an approved fire clearance for 8 bedridden residents. A delayed egress door system was observed and the alarm system was tested and operational. The resident rooms were observed to be have sufficient space to accommodate the resident's furnishings, and have all of the required furniture with plenty of personal storage space. Resident bathrooms in rooms #103, 104, 209, 325, 326, and 301 were observed to have a working toilet, wash basin, and shower to accommodate non-ambulatory residents. Each bathroom had the required grab bars and non-skid mats. The public restrooms were observed to have working toilets and wash basins. Report Continued on LIC809-C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: OAKMONT OF COVINA HILLS	FACILITY NUMBER: 198603545
	VISIT DATE: 08/02/2022

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The water temperature in each resident bathroom and public bathroom tested within the required 105*F-120*F temperature, per Title 22 Regulations. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen was observed to be stored in the laundry room, that is kept locked and inaccessible to residents. The facility has a telephone system is that is a landline and is operational, available for resident use. Emergency Exit plans are posted and readily available for review at near each elevator door and facility entrance/exit.Several fire extinguishers were located and mounted on the walls down each hallway. They were observed to have recent inspections and be fully charged.
Dishes, cups and flat ware are stored in the dining rooms and kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked in the locked central kitchen where food is prepared. The food supply was observed in the kitchen was more than the required 7-day non-perishable and 2-day of perishable food available for the residents.
Smoke/carbon monoxide detectors were observed in each resident bedroom, and were tested and operational at the time of the visit. The facility also has an electrical and connected fire system that was tested and operational by Covina Fire Department on 06/28/22.
Stove burners, ovens, microwaves, washers, and dryers are working. There are refrigerators located in the assisted living resident bedrooms, and one in the central kitchen. Each refrigerator has a measured temperature of at least 45*F for appropriate food storage. Freezers are at 0*Ft. The facility is equipped with central air and heat and each client bedroom is individually climate controlled.
All poisons, toxins, and cleaning supplies are locked in the housekeeping closets and are inaccessible to residents in care. First aid kits were inspected and observed the have the required supplies and first aid manual to meet Title 22 Regulations. All staff and resident files will be kept in the director's office on the second floor.

LPA's Maldonado and Villalobos cleared the physical plant and conducted the Component III Orientation with the applicant.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC809 (FAS) - (06/04)

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