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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002255
Report Date: 11/09/2021
Date Signed: 11/10/2021 06:56:25 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COVINGTON, THEFACILITY NUMBER:
306002255
ADMINISTRATOR:EILEEN LEA DAVISFACILITY TYPE:
741
ADDRESS:3 PURSUITTELEPHONE:
(949) 389-8500
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY:343CENSUS: 178DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lea Davis and Nicole AyalaTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Executive Director Lea Davis and explained the reason for the visit. Resident Services Director Elisa Walker and Director of Residential Health Services Nicole Ayala were present as well.
At 1:22 PM, LPA toured the facility with Director of Residential Services Ayala and Resident Services Director Walker. Facility has 148 residents in Independent Living, 19 residents in Assisted Living, and 11 in memory care during today's visit with 7 residents on hospice care. Facility consists of Independent Living, Assisted Living and Memory Care units. Facility has 2 restaurants in the Independent Living as well as a hair salon, secured indoor swimming pool, gym, chapel, multiple activity rooms and a library. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor computerized sign in system. LPA observed the first aid kit/ area in both Independent Living and Assisted Living and has all required items. Facility mitigation plan has been approved. Facility has emergency evacuation chairs at the stairwell. LPA observed an ample supply of emergency food. Facility tests smoke detectors quarterly through an outside agency, Cosco. LPA toured the outside grounds and observed multiple outside visitation areas. LPA observed a koi pond on the Independent Living side of the property. LPA observed the medication room and facility uses electronic medical records for medication management. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and all files are up to date including emergency information. Most residents and all staff are vaccinated for Covid-19.
LPA consulted with Executive Director Davis regarding the pond on the Independent side. Executive Director to look into additional safety features for the pond and update LPA.
No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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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