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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002255
Report Date: 05/26/2022
Date Signed: 05/26/2022 12:29:22 PM


Document Has Been Signed on 05/26/2022 12:29 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, 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: 180DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director (ED) Donald Cash BentonTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Albert Marin and Celine De Perio conducted an unannounced required annual inspection in this facility.

This facility is licensed for capacity of 343 of which 160 are non-ambulatory on the first and second floor only and 6 bedridden on the first floor only. And with hospice waiver for 15. For this visit, there were 8 residents under hospice care.

LPAs Marin and De Perio were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedures. LPAs met with Executive Director Donald Cash Benton; and stated the purpose of this visit.. With ED, LPAs conducted a tour of the interior and exterior portions of the assisted living, memory care and the independent living buildings of the facility. LPAs inspected random resident's rooms which were provided with furniture in good repair, clean linens, and free of tripping hazards. Random private bathrooms were observed to be provided with grab bars and non skid floors mats. Hot water temperatures were measured from 115 to 116 degrees Fahrenheit. Delayed egress in memory care unit was tested and observed to be operational. Resident rooms were observed have individual smoke alarm. individual carbon monoxide detectors were observed in resident's rooms in the independent living building. Last fire inspection conducted by private company was completed last March 2022. Evacuation chairs were observed in stairwells located in the assisted living and independent living buildings. Paging systems were randomly tested and observed to be functional. Common areas in the facility included but not limited to library, theater, chapel, audio visual room, and gym areas. Hallways were observed to be well lit and free of any obstruction hazard. LPAs observed activities and menus posted in common areas. Facility has an indoor pool feature and secured by a key card activated doors. Dining halls and kitchens were observed to be in good repair. LPAs observed daily temperature logs for the refrigerators, freezers and dishwashers. Outside features had furniture in good repair and adequate shaded areas. LPAs also discussed the Assembly Bill 665.

For this visit, no deficiencies were noted for areas observed. No citation was issued.

LPAs Marin and De Perio conducted an exit interview with ED Benton and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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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