Routine inspection·March 9, 2026

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: T he 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 Direc tor's office, Wellness director office, Resident coordinator office, Assistant director office, M emory 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 obstru ction 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**** 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.