The Covington

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Allegation investigated: Facility staff failed to assist resident with bathing and personal hygiene.

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct an investigation into the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Cash Benton and discussed the purpose of the visit. The facility allegation regarding Facility staff failed to assist resident with bathing and personal hygiene revealed the following: LPA reviewed an Admission Agreement for Resident #1 (R1) signed and dated by R1 and facility staff on March 21, 2025, with an effective date of March 25, 2025, stating that R1 was independent with a score of 0 for level of care. LPA reviewed a physicians report for R1 dated April 2, 2026, stating that R1 has a cognitive condition of Mild Cognitive Impairment (MCI), does not have motor impairment and can bath themselves, but needs reminders and does not have bladder or bowel incontinence. This medical assessment was signed and dated by a medical professional on April 2, 2026. LPA reviewed a note in R1s file from a different medical professional stating that R1 was diagnosed with Dementia on June 4, 2025. Continue on LIC9099C Unsubstantiated LPA reviewed a service plan for R1 dated December 18, 2025, that states that R1 is able to complete personal grooming daily, R1 is able to bathe and shower without assistance with cueing and set up assistance as needed Interviews with R1 revealed that they are alert and oriented to time and place. R1 informed LPA that they are independent and can shower on their own and will continue to shower independently for as long as they can. R1 informed LPA that the staff will offer assistance, but R1 refuses. R1 informed LPA that they try to shower 3 times a week but does not always stick to that routine. R1 informed LPA that they are able to use the restroom by themselves and the only help they rely from facility staff is medication management. Interviews with 5 of 7 residents not including R1 informed LPA that if they ask for assistance with anything, the staff will help. 4 of 7 residents informed LPA that staff will specifically assist with showers when they ask for it. 4 of 7 residents informed LPA that the staff come in a timely manner and assist whenever it is needed. 2 of 7 residents did not confirm or deny the allegations. Interviews with 6 of 6 staff revealed that R1 is independent and can shower on their own. 5 of 6 staff informed LPA that they address the concern of body odor with R1 and offer assistance that is refused. 5 of 6 staff informed LPA that there is evidence of R1 taking a shower due to the body odor going away and R1s shower being used at least once a week. 6 of 6 staff informed LPA that they do not force R1 to take a shower due to their personal rights. 1 of 6 staff informed LPA that 18 residents are in the assisted living building of the facility along with 9 residents in memory care with the rest of the residents completely independent or having a private caregiver. Interviews with Witness #1 (W1) revealed that they are concerned that the facility is not assisting with R1s hygiene needs and stated that R1 has not showered for almost a year. W1 informed LPA that they have not been at the facility to visit R1 since December of 2025. LPA reviewed staff files and observed 6 of 6 staff have updated training's on the topics of residents rights and assisting with activities of daily living. Based on information gathered and interviews conducted, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 22-AS-20260601160629

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to The Covington. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 343 of which 160 may be non-ambulatory and 6 bedridden. There are a combined total of 222 residents today including independent living, assisted living and memory care. Facility has an approved hospice waiver for 20 residents and the facility currently has 5 residents on hospice care. Cash Benton has an administrator certificate expiring on 11/28/2026. LPAs Lyman and Mendivil along with Director of Health and Wellness Nicole Ayala toured the facility at 8:50 AM. Administrator Cash Benton joined the tour in progress. LPAs toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. Facility consists of a four story independent living building, twenty two independent living cottages and a two story assisted living/ memory care building. Throughout the different buildings, LPAs observed multiple outside areas, two dining rooms, beauty salon, fitness area, theater, activity areas and a secured swimming pool. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 111.7 and 119.3 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Staff responded within 5 minutes for emergency pull. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had required elements including thermometer, tweezers and scissors. LPAs observed cleaning supplies are secured. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. CONTINUED ON LIC 9099C DATED 05/12/2026 Facility is keeping a log of freezer/ refrigerator temperatures and were within range. Smoke detectors and fire inspections are conducted annually by an outside company, Cosco with the last inspection date in March 2026. Fire extinguishers are fully charged. LPAs observed evacuation chairs at stairwells. LPAs toured the outside grounds and there is ample shaded seating for residents. LPAs observed ample emergency food and water. LPAs reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility conducts quarterly emergency drills with the last drill conducted on 04/10/2026. Facility provides activities in the form of games, exercise, and outings in the community. LPAs observed residents participating in activities during the visit. LPAs spoke with residents during the visit who stated satisfaction with facility services. LPAs observed no health or safety concerns during the visit. LPAs reviewed select resident and staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen/TB, training and criminal record clearance. LPAs reviewed medication administration and storage. Medications are stored in a locked medication cart. Medications appear to be administered per physician order. Based on the observations made during today's visit, no deficiencies are being cited. Exit interview conducted and a copy of this report was given at time of visit.the state’s words, verbatim · CDSS document, May 12, 2026

Allegation investigated: Resident sustained multiple wounds while in care.

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. An initial investigation visit was conducted on April 21, 2022 by the Department. It was alleged resident sustained multiple wounds while in care. During the investigation, LPA Arias conducted an interview with staff. LPA Arias reviewed records obtained. The investigation determined as follows: Regarding the allegation resident sustained multiple wounds while in care, it was reported resident had multiple skin/wound issues that were severe as wounds had been neglected and not cared for. LPA reviewed records for resident 1 (R1). R1 was admitted to assisted living on May 12, 2021. R1 was prescribed topical steroid ointments to aid with itching on May 9, 2021 and again on June 8, 2021 for daily usage. R1's physician's report dated April 26, 2022 indicated R1 had a history of skin tears due to thin skin. Continued on 9099-C dated 09/04/2025 Unsubstantiated The physician's report also indicated R1 could communicate their needs. R1 had a diagnosis of cardiovascular disease, hypertension, and transient ischemic attack. R1's most recent physician's order dated April 21, 2022 included blood thinning medication for R1's conditions. LPA was unable to review home health records as they were not available. LPA interviews with three out of four staff stated they were familiar with R1. Three out of three staff stated R1 was using topical steroid cream on a daily basis for itch relief and could cause thinning of the skin when used often. Two out of three staff added in-service training was provided to care giver staff regarding the repositioning and transfers of R1 to minimize bruising and skin tears. One out of three staff added R1 was on blood thinners and that would have contributed to R1's bruising and instructed R1 to call for help when ambulating. On August 10, 2021, R1 had a fall with skin tears. Tears were treated. Home Health was requested and approved by physician. On January 4, 2022, R1 had a fall with skin tears. Tears were treated. Physician was notified and provided treatment plan. On March 5, 2022, R1 had a skin tear that was treated. Physician was notified and provided treatment plan. On March 10, 2022, R1 had a fall with skin tears. Tears were treated and physician and daughter were notified. On April 13, 2022, R1 had a fall with skin tears. Tears were treated. R1 was sent to the hospital for further evaluation due to hallucinations. R1 was discharged from the hospital and returned to the facility on April 18, 2022. R1 was placed into hospice on April 18, 2022 due to diagnosis of cerebral atherosclerosis. R1 passed on April 25, 2022. Therefore based on staff interview and records observed, the allegation of resident sustained multiple wounds while in care is therefore deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of the report was left with the facility representative.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 22-AS-20220413123916

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to The Covington. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 343 of which 160 may be non-ambulatory and 6 bedridden. There are a combined total of 217 residents today including independent living, assisted living and memory care. Facility has an approved hospice waiver for 15 residents and the facility currently has 13 residents on hospice care. Cash Benton has an administrator certificate expiring on 11/28/2026. LPAs Lyman and Mendivil along with Assistant Living Director Irene Falcon toured the facility at 8:51 AM. Administrator Cash Benton joined the tour in progress. LPAs toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. Facility consists of a four story independent living building, twenty two independent living cottages and a two story assisted living/ memory care building. Throughout the different buildings, LPAs observed multiple outside areas, two dining rooms, beauty salon, fitness area, theater, activity areas and a secured swimming pool. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 106 and 110 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Staff responded within 5 minutes for emergency pull. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had required elements including thermometer and scissors. LPAs observed cleaning supplies are secured. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility is keeping a log of freezer/ refrigerator temperatures and were within range. CONTINUED ON LIC 809C DATED 06/05/2025 Smoke detectors and fire inspections are conducted annually by an outside company, Cosco with the last inspection date in September 2024. Facility has carbon monoxide detectors in resident rooms and are tested by Cosco as well. Fire extinguishers are fully charged. LPAs observed evacuation chairs at stairwells. LPAs toured the outside grounds and there is ample shaded seating for residents. LPAs observed ample emergency food and water. LPAs reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility conducts quarterly emergency drills with the last drill conducted on 02/19/2025. Facility provides activities in the form of games, exercise, and outings in the community. LPAs observed residents participating in activities during the visit. LPAs spoke with residents during the visit who stated satisfaction with facility services. LPAs observed no health or safety concerns during the visit. LPAs reviewed select resident and staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen/TB, training and criminal record clearance. LPAs reviewed medication administration and storage. Medications are stored in a locked medication cart. Medications are being administered per physician order. Based on the observations made during today's visit, no deficiencies are being cited. Exit interview conducted and a copy of this report was given at time of visit.the state’s words, verbatim · CDSS document, Jun 5, 2025

Allegation investigated: Facility did not issue a refund to former resident.

On today's date, Licensing Program Manager (LPM) Bethany Moellers delivered complaint findings of the above allegation to Administrator, Donald Cash Benton. The findings were delivered via phone and emailed for signature. The reporting party (RP) alleges facility did not issue a refund to former resident (R1). Based on LPMs interviews conducted and records obtained a refund has been issued per signed admission agreement. R1 moved out of the facility June 2021 and was issued 90% of the entrance fee within fourteen days after new resident moved in, as stated under the reoccupancy benefit outlined on pages 16 and 17 of the admission agreement. Interview with RP confirmed amount owed was given and they have no further concerns. Proof of payment received from the facility. LPM determined that the allegation is UNFOUNDED. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview conduct and no citations issued. Unfoundedthe state’s words, verbatim · CDSS document, May 12, 2025 · control 22-AS-20230606135122

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on fire evacuees relocated to the facility. LPA was greeted and granted entry into the facility and explained the reason for the visit. On 01/08/2025, facility accepted 23 evacuees from their sister facility MonteCedro in Altadena. Select staff from MonteCedro are working at the facility as well. At 1:00 PM, LPA toured the facility and observed the following: Facility appears clean and sanitary. LPA observed ample emergency food and water as well as the emergency disaster plan. LPA spoke with evacuees who verbalized satisfaction with facility services as well as feeling safe and taken care of. Facility has provided clothing and incidentals to the evacuees. Facility estimates a stay time of approximately three weeks. No health and safety concerns noted. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 15, 2025

Type of visit: Required - 1 Year

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] 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.the state’s words, verbatim · CDSS document, Aug 20, 2024