306002255-8-20-2024-22-AS-AROS-D8BVEY-20240820162304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002255
Report Date: 08/20/2024
Date Signed: 08/20/2024 04:23:11 PM

Document Has Been Signed on 08/20/2024 04:23 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	COVINGTON, THE		FACILITY NUMBER:	306002255
ADMINISTRATOR:	DONALD CASH BENTON		FACILITY TYPE:	741
ADDRESS:	3 PURSUIT		TELEPHONE:	(949) 389-8500
CITY:	ALISO VIEJO	STATE: CA	ZIP CODE:	92656
CAPACITY:	343	CENSUS:	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Executive Director Cash Benton		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 Analysts (LPA) Amy Rodgers conducted an unannounced Required One Year visit to ensure substantial compliance with Title 22 regulations. This facility is co-licensed as a Continuing Care Retirement Community (CCRC) for up to 343 resident capacity, of which is 160 is non-ambulatory on the 1st and 2nd floors only and 6 bedridden on the first floor only. Hospice waiver for six (6). LPA was granted entry into the facility and was met by Executive Director (ED) Cash Benton with whom LPA discussed the purpose of the visit. LPA was accompanied by Executive Director Benton, during a tour of the facility, which was conducted inside and out including a sample of resident units, the dining area, recreation rooms, outside grounds, and food storage areas. Exterior and interior passageways were free from obstructions. Pathways were free of obstruction and slip hazards. There is an indoor pool securely locked and accessible by key card to residences. There are waters features throughout the facility that are only accessible to independent residents. Smoke and carbon monoxide alerts are hard wired to a central location. All doors and elevators were operational. Emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in rooms or in locked facility storeroom. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COVINGTON, THE	FACILITY NUMBER: 306002255
	VISIT DATE: 08/20/2024

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CONTINUED FROM 809]

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted and available through the facility communication application. Central cleaning supplies were stored in a locked closed room. Centrally stored medications were properly stored and locked in medication carts. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

Staff records review verified that all staff records are complete and compliant. LPA conducted a thorough review of In-service training procedures. All direct care staff have current First Aid and CPR training. Resident records reviewed and confirmed compliant. Administrator’s certification is current.

LPA interviewed multiple staff and clients. The interviews did not raise any significant licensing concerns. LPA reviewed the theft and loss policy and procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted, this report was discussed with Executive Director Benton. The report along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Executive Director Benton.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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