Regency Grand at West Covina.

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**** 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 26 27 28 29 30 31 32 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.

The investigation revealed the following: In regards to the allegation: "Staff are not providing nutritious meals to residents in care." It is alleged that residents have not been served nutritious meals, and facility has not provided healthier options like fruits and vegetables. During interviews with the residents, thirteen (13) out of (13) interviewed did not corroborate the allegation. Interviewed residents stated that they like the food served to them and the facility provide them fruits and vegetables all the time. In addition, residents stated that they are satisfied with the quality of the food provided and they also get to choose from the alternate menu if they request for it. During interviews with four (4) staff, all denied the allegation that residents are not provided nutritious meals. S1-S2 stated that they use a meal planning service company to customize and approve menus for the facility. They use (5) weekly menus that they rotate on a quarterly basis and the meal plan/menus are approved by a registered dietitian. Furthermore, S1-S2 indicated that they have not heard any complaints from the residents regarding the nutritious meals they are served. LPA's review of the staff files revealed that the cooks have the proper training and culinary experience. During the tour of the kitchen and dining area, LPA observed that residents were served a balanced plate with lean protein, whole grains, vegetables and a bowl of assorted fruits. LPA also observed sufficient food supply for 7 days non perishables and 2 day perishables including fresh fruits and vegetables. Based LPA's observations and on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Mary Mims-Burris, Executive Director.

Furthermore, S1 checked on R1 the next day, who stated she was doing well. S1 indicated that R2 has been repeatedly reminded of the residents’ rights and the house rules. S1 met with R2 on 06/13/2025 at 2pm to address the issue and R2 was verbally warned that if the behavior continues in the future, R2 must move elsewhere. Today, both R1 and R2 were interviewed, and they believed the issue was resolved. (12) out of (12) residents interviewed feel safe and comfortable in the community. (11) of (12) residents interviewed denied being bullied by other residents. Additionally, residents stated that if they have issues, the staff are always available to talk to and act on resolving the issue right away. Documentation reviewed and interviews conducted do not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview held and a copy of the report was provided to Mary Mims-Burris, Executive Director

Licensing Program Analyst (LPA) Daniel Konishi conducted the Unannounced required annual inspection. LPA arrived unannounced and met with the Executive Director, Mary Mims-Burris and assisted with the visit. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for 49 ambulatory and 111 non-ambulatory. Currently, the facility has 11 hospice waiver residents and 6 home health residents. The initial annual visit was conducted on 04/24/2025. During the initial visit the following eight (8) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Operational Requirement, Physical Plant Environmental Safety, Resident Right-Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness. During today’s annual visit, the following four (4) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Staffing, Personnel Records-Training, Resident Records-Personnel Reports, Resident with Special Health Needs. Staffing: Facility has sufficient staffing for care and supervision to the residents. Personnel Records-Training: All the staff in the facility are over 18 years old and fingerprint cleared with the facility. The administrator is Mary Mims-Burris and her administrator certificate expires on 10/02/2025. LPA reviewed all nine (9) staff files and they all have the required documents in file which included: health screening, TB test result, employee rights, required training hours and updated first aid certificate. 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 26 27 28 29 30 31 32 Resident Records-Incident Reports: LPA inspected eleven (11) residents files which include eight (8) residents files from Assisted Living and three (3) residents files from Memory Care and they all have the required documents in file which included: admission agreements, Physician's Reports, Updated Needs and Service Plan, Pre-appraisal, TB clearance, Physician’s Orders, Personal Rights, and medication records. Resident with Special Health Needs: No residents in the facility with prohibited health conditions. No residents in the facility with postural supports. Currently there are eleven (11) residents on hospices and six (6) residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. There are interior and exterior space available on the facility premises to permit residents with dementia to wander freely and safely. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit Interview conducted and a copy of the report were provided to the Executive Director, Mary Mims-Burris.

Interviews with residents revealed 9 out of 9 residents interview stated staff are respectful, calm when addressing residents, and helpful around the facility. One resident stated to have felt blamed over an incident with the physical plant of the facility. Interviews with staff revealed 7 out of 7 staff stated staff are respectful when speaking to the residents, communication with residents is professional, and they always maintain a calm manner. Administrator stated that upon an incident with that resulted in a lot of damage from a resident’s shower, administrator questioned the resident how the handle broke. However, Administrator did not blame the resident of using tools to break the shower handle. Therefore, although the resident felt administrator was blaming the resident for breaking the shower handle there is not sufficient evidence or witnesses to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Regarding allegation: Facility is in disrepair. It is alleged bathroom handle broke on 2/14/25 and resident reported it many times prior to that, which has resulted in resident not being able to shower in own bathroom. Interviews with residents revealed 8 out of 9 residents have either not experience anything in their rooms to be in disrepair or facility’s staff have successfully repair reported items in a timely manner. 1 out of 9 residents stated to have had difficulties with shower handle and on one occasion the shower handles broke, with water gashing out. Per R1 since the shower in their room was out of order, facility staff provided assistance in a vacant room to use the shower while the shower was repaired. Interviews with staff revealed when an item is reported to be repaired in the residents’ room, maintenance is quick to respond and finish repairs. Interview with maintenance assistant revealed, staff responded three times prior the incident in which the water gashed and replace parts inside the shower handle or shower handle. Per maintenance staff the shower handles are all uniform in each room and replacement supplies are the same as well. They also stated that the mechanism of the shower handle must be treated in a gentle manner without excessive turns or turning all the way as the screw inside can break off. Which is what happened in room #354’s shower handles each time it was replaced. Per maintenance assistance, the three times the shower handle was repaired, staff explained to the resident how to use the shower handles to prevent them from breaking again. Administrator explained that the last time the shower handles broke, the shower was out of order for a couple of weeks as they had to replace the dry wall and provided a similar mechanism to the shower handle which has been better for the resident. During facility's tour conducted on 3/6/25 and 3/25/25 facility was observed in good repair. (CONTINUED ON LIC 9099C) 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 26 27 28 29 30 31 32 Documents reviewed revealed maintenance staff responded to the following work order dates in room #354; On 12/30/24 staff greased the area of shower handle. On 1/15/25 staff removed and replaced the shower handles. On 1/19/25 shower cartridge was replaced. On 2/1/25 shower cartridge was replaced. Incident report dated 3/7/25 notes incident occurred on 2/14/25 in which “shower stem broke into the wall.” Although the shower handles broke more than once, facility staff replaced it each time and assisted R1 with guidance to use the handles properly. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Mary Mims Burris and a copy of this report was provided.

Licensing Program Analyst (LPA) Christine Wong conducted an Annual/Required visit by using the Compliance And Regulatory Enforcement (CARE) Tools on 03/12/24 but due to time restrains and LPAs Christine Wong and Daniel Konishi has returned on today's date 03/14/24 to finish the remaining Ten ( 10) domains. LPA met with Receptionist Debbie Golden who allowed entry into the facility and Shortly after, the Administrator Mary Mims-Burris arrived and assisted with the visit On today's date, LPA inspected the Nine (9) domains include: Infection Control, Operational Requirement, Staffing, Personnel Records-Training, Resident Right-Information, Planned Activities, Incidental Medical and Dental, Resident Records and Incident reports, Disaster Preparedness and Residents with Special Health Needs. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirement: T h e c urrent plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 15 residents is approved. A fire clearance approved for 49 ambulatory and 111 non-ambulatory with no bed ridden residents. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($2,000,000) is in place. 3. Staffing- Facility has sufficient staffing for care and supervision to the residents. 4. Personnel Records-Training: All the staff in the facility are over 18 years old and fingerprint cleared with the facility. The administrator is Mary Mims-Burris and her administrator certificate expired on 10/2/23 and currently is pending application in our internal CCL system since 10/3/23. LPA reviewed all 10 staff files and they all have the required documents in file which included: health screening, TB test result, required training hours and updated first aid certificate. 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 26 27 28 29 30 31 32 5. Resident's Right Information: L PA observed the required posters posted nearby the residents' mailbox which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. 6. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted and LPA reviewed the calendar for both Assisted Living and Memory Care Unit. The facility does have an active Resident Council. 7. Incidental Medical and Dental: LPA inspected eight (8) residents' medication which include (3) from Assisted Living and (5) from Memory Care Unit and they are centrally stored and locked in the medication room and they are seemed accurate and updated and also contained 30 days supply of medication. The facility would also provide medical and dental transportation if needed. 8. Resident Records-Incident Reports: L PA inspected 10 residents files and they all have the required documents in file which included : admission agreements, Physician's Reports, Updated Needs and Service Plan, Pre-appraisal, TB clearance, Physician's Orders, medical consent, and medication records. 9. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and its updated on 03/2024. The last fire drill was conducted on 01/18/24 The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training. 10. Resident with Special Health Needs. N o r e sidents in the facility with prohibited health condition. Currently there are 11 resident on hospices and two residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. Exit Interview conducted and a copy of the report was provided.

Licensing Program Analyst (LPA) Wong conducted the Unannounced required annual inspection. LPA arrived unannounced and met with Administrator Mary Mims-Burris and assisted with the visit. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for 49 ambulatory and 111 non-ambulatory. Currently, the facility has 11 hospice waiver residents and 3 home health residents. On the above date, LPA completed the domain of Physical plant and environmental safety and food service today. Physical Plant and Environmental Safety: The facility is a three story building. The first floor includes memory care unit and assisted living resident's rooms, main lobby, administrative office, Bristol, wellness director office, two activity rooms, resident coordinator office, assistant director office, Chart room, Library, Multi-purpose room, resident mail box, community laundry room, dining room and facility kitchen. The 2nd floor includes laundry room, activity room, unisex bathroom and assisted living residents' rooms. The 3rd floor include laundry room, activity room, exercise room and unisex bathroom and assisted living residents' rooms. During the facility tour, LPA inspected Room #135, #106. #123, #117, #221, #216, #250, #353, #320 and #321 and they all have sufficient lighting and required furniture in the residents rooms. For the resident bathrooms, they are clean, sanitary and in a good working condition. All the residents bathrooms have the required Non skid mat and grab bar in the bath tub and toilet. LPA tested the hot water temperature and they are between 112.4 and 116.6 degrees F which are within the Tittle 22 regulation. The carbon monoxide detector is located in the laundry room and it's working properly. LPA reviewed the annual fire inspection and testing report via the state fire marshal and everything is working well. All the cleaning solutions and chemicals are locked in the janitor room and inaccessible to the residents. Facility has a telephone service on the premises. The backyard / rear grounds of the facility is well landscaped and the passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash can or containers have the covered lids. 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 26 27 28 29 30 31 32 Food service: Currently the facility has about 12 residents in the Assisted Living and 2 residents in the Memory Care Unit are required to have modified diet and LPA reviewed and observed the doctor's order. The facility has ample supply for two days perishable and seven days non-perishable food supply. The facility kitchen is clean and kept free of litter, rodents and insects. All food in the facility are stored properly. Due to time restraint and LPA was not able to complete the full inspection tool and interview residents and staff and LPA will come back at another time to complete. On today's date, there's no deficiencies were observed. Exit Interview and copy of the report was provided.