198603428-3-9-2026-28-AS-BPEA-DRZVD2-20260309162001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603428
Report Date: 03/09/2026
Date Signed: 03/09/2026 04:20:20 PM

Document Has Been Signed on 03/09/2026 04:20 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	REGENCY GRAND AT WEST COVINA		FACILITY NUMBER:	198603428
ADMINISTRATOR/ DIRECTOR:	MIMS-BURRIS, MARY		FACILITY TYPE:	740
ADDRESS:	150 SOUTH GRAND AVENUE		TELEPHONE:	(626) 332-3344
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 160		CENSUS: 124	DATE:	03/09/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:42 AM
MET WITH:	Mary Mims-Burris - Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA met with Mary Mims-Burris, Executive Director and explained the purpose of the visit. The facility is licensed to serve age range 60 and over, approved for (49) ambulatory and (111) non ambulatory including those in memory care unit with delayed egress. Hospice waiver approved for 15 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are trained in the proper use of required PPEs. The emergency infection control plan has been reviewed/updated as recommended. The plan was last reviewed on 02/11/2026.

Operational Requirement: The plan of operation included the Infection Control Plan. The facility has a Dementia Waiver in place. A hospice waiver for (15) residents is approved. A fire clearance is in place, approved for 49 ambulatory and 111 non-ambulatory with no bedridden residents. Liability Insurance in the amount of ($1,000,000) per occurrence and total amount of general aggregate ($3,000,000) is valid, expires on 09/01/2026.

Physical Plant/Environment Safety: The facility is a three story building. The grounds in the facility are well landscaped and have a leveled walkway to the entrance of the building. The facility consists of: First floor: Main lobby, Administrative offices including Executive Director's office, Wellness director office, Resident coordinator office, Assistant director office, Memory care unit, Assisted living resident's rooms, Multi purpose room, Residents' mailboxes, Bistro, Lounge, Library, Dining room, Community laundry room, Unisex bathrooms, (2) Elevators, Kitchen, Pantry and Main patio by the main entrance. Second floor: Assisted living residents' bedrooms, Activity room/lounge, Community laundry room and Unisex bathroom. Third floor: Assisted living residents' bedrooms, Community laundry room, Billiard/Activity room, Gym and Unisex bathroom. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with cameras installed in the hallways near the elevators. Each residents' room has their own bathroom, mini kitchen and balcony. The bathrooms were observed to be clean and operational with grab bars and non skid mats. Cleaning supplies and toxic substances are inaccessible to residents. LPA toured and tested hot water temperature in eight (8) random resident rooms in different floors (Rooms #134, #135, #238, #252, #317, #325) and (Rooms #118, #122) in Memory Care unit. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The kitchen was observed and there was a sufficient amount of perishable and non-perishable food supplies, however, food supplies were not stored in an organized manner. Fire extinguishers were observed throughout the facility and were fully charged, last serviced on 01/09/2026. The carbon monoxide detectors are operable and in compliance. Facility has fire sprinklers. LPA reviewed the annual fire inspection and testing report. Pull Fire alarm system observed and connected to the City of West Covina Fire Department. Delayed egress devices in place. *****REPORT CONTINUED ON LIC809-C****

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REGENCY GRAND AT WEST COVINA	FACILITY NUMBER: 198603428
	VISIT DATE: 03/09/2026

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Staffing: There are adequate staff members to provide care and supervision to the residents, including the Administrator. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator's certificate is valid, expires on 10/02/2027.
Personnel Records-Training: LPA reviewed (6) staff files. Proof of staff training, health clearance, vaccinations, food handling certificate, and 1st Aid/CPR training are current.
Resident Rights-Information: Resident personal rights and complaint hot line information posters are posted. The facility provides internet services to all residents and have access to the facility phone.
Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted outside the main dining room and displayed on a television in the common area. Some special activities were also posted inside the elevators. The facility has a Resident Council.
Food Service: Sufficient food supply is stored in the kitchen and pantry area consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. LPA observed that the food supplies are not organized, the refrigerator included left over that were not properly covered and unlabeled food items. LPA also observed personal items such as sweater and a small bag inside the food pantry.
Incident Medical and Dental: Residents medications were reviewed containing 30-day supply of medications to confirm medication is given as prescribed and is documented properly. The facility uses the Electronic Medication Administration Record (EMAR) log to document medications given. Medications are centrally stored and locked in the medication room. Facility uses medical carts. Medical and dental transportation is provided. First aid is available in the assisted living and memory care units medication rooms.
Resident Records/Incident Reports: A total of ten (10) resident files in both assisted living and memory care units were reviewed. They contained Admission Agreements, ID and Emergency information, Physician's Reports, Pre Placement Appraisal, Functional Capability Assessment, Medical Consent and Personal Rights.
Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place.
Residents with Special Health Needs: Nine (9) residents are under hospice care and a complete hospice care plan is maintained in the facility. Thirteen (13) residents are using oxygen and "No smoking In Use" signs are posted on the residents doors. Appraisals were observed in resident files.

No deficiencies cited. Technical advisories issued. Exit interview conducted and a copy of the report was provided to Mary Mims-Burris, Executive Director.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026

LIC809 (FAS) - (06/04)

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