Routine inspection·April 6, 2022

Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Administrator Douglas Fuller and Director of Nurses Cita De Jesus and informed the purpose of visit. LPA also met with Housekeeping Supervisor Rosario Figueroa and LVN-Director of Staff Development Cynthia Angeles. Facility has an approved LIC808 Mitigation Plan. Staff were fit tested for N95 respirators on March 2021. Facility is to recertify staff for N95 fit testing. LPA inspected the facility inside out with Cita De Jesus and Rosario Figueroa and later joined by Douglas Fuller. The assisted living side of the facility has five buildings namely the Azalea Cottage, Garden Cottage, West Wing, Peralta Cottage and Mission Cottage. LPA randomly selected for inspection seven (7) residents rooms. LPA also inspected the living room, dining area, kitchen, bathrooms, toilets, shower room and yard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. Facility uses mechanical means of cleaning/rinsing dishes and utensils. Lamp and lights were present in all rooms. Toilet, hand washing and bathing areas were observed in operating conditions. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch temperature probe. Surgical masks and disposable gloves are readily available at the screening station. Checking of visitor's temperature and symptom checks are done at entry for all staff and visitors. Residents are screened for COVID-19 symptoms and temperature checked daily. Facility keeps record of proof of vaccination of visitors and antigen test kits are readily available at the screening station. Trash bins were observed with foot pedal operated lids. .......continued on LIC809C Facility has working carbon monoxide and smoke detectors. Hot water temperature in one of the toilets was tested and measured at 120 degrees Fahrenheit. LPA checked one of the fire extinguishers and observed fully charge with tag showed serviced February 10, 2022. At 1:13 pm, LA observed gallon of peritoneal cleanser in one of the toilets/restrooms' unlocked cabinet. On this same day, LPA obtained copy of proof of $3M liability insurance coverage. LPA requested for copies of the following updated documents to be submitted to Community Care Licensing (CCL) by April 20, 2022: 1. LIC500 Personnel Report 2. LIC610E Emergency Disaster Plan Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Douglas Fuller. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.