Routine inspection·February 10, 2022

At approximately 12:55 PM, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, annual inspection using the Infection Control Domain of the Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator and disclosed the reason for the visit. Census: 72 Entry: LPA observed signs pertaining to the facility’s visitation policy and masking requirement at the main entrance. LPA observed a rear entrance for employees which had a digital thermometer, hand sanitizer, surgical masks, and an employee log with daily symptom and temperature documentation. Screening: Upon entry, staff screened LPA for temperature and symptoms. Staff prompted LPA to record temperature, any symptoms, and contact tracing information in a visitor log. 4 bottles of hand sanitizer were available at the entrance. LPA also observed signs for coughing etiquette, social distancing, handwashing, signs and symptoms of COVID-19, cleaning practices, and droplet precautions. At approximately 1:15 PM, LPA conducted a physical plant tour. Elevator: The facility had one elevator. The elevator had a sign for social distancing which noted a limit of 2 persons at a time. LPA observed a posting for the facility’s emergency evacuation routes which was clearly labeled. Bedrooms: LPA and Administrator toured vacant and occupied bedrooms on the first and second floor. All bedrooms were tidy with operational appliances. LPA observed lamps, nightstands, beds, linens, and private bathrooms with liquid soap, hand towels, and trash cans. Private bathrooms also had grab bars in the showers and around the toilets. Bathrooms: The facility currently has one public restroom on the first floor. The bathroom was sanitary with liquid soap, paper towels, handwashing instruction sign, and a trash can with a tight-fitting lid. Outside of the bathroom was the facility’s telephone. It is a payphone, but quarters are available free of charge at the front desk. The facility has an additional telephone on the second floor for incoming resident calls. Common Areas: All hallways had signs about COVID-19 policies and precautions in both English and Spanish. All floors, walls, and ceilings were clean. Furniture in the dining room, lounges, living room, and activity room were clean and in good repair. Hand sanitizer was readily available. Facility posted the most recent Community Care Licensing (CCL) Provider Information Notice at the front desk, along with recent CCL reports, an activity schedule, resident rights poster, and a confidential complaint hotline. Fire Safety: LPA observed 2 fire extinguishers on the second and 1 on the first floor. All extinguishers were fully charged and last inspected on 02/07/2022. All smoke detectors tested were operational. The facility has fire sprinklers throughout the inside of the facility, resident bedrooms, hallways, dining room, and outdoors as well. Outdoor Space: LPA and Administrator toured the outside space. Benches had red X’s made of tape to designate social distancing areas. A set of benches which were too close were taped off. Two gazebos were designated for resident smoking, had ashtrays, and were at least 20 feet from buildings. LPA observed 2 locked storage sheds which contained gardening tools. LPA and staff walked on the south side of the facility’s exterior and tested an exit door which was unlocked from the inside. LPA observed an electronic gate on the north side of the facility’s exterior which led to the employee parking lot. Laundry: In the back parking lot, LPA observed a laundry room with 2 washers and 1 dryer. Administrator explained that resident laundry is cleaned on an individual basis. The facility can sanitize the machines after each use. Medication Room: LPA and Administrator entered a locked Medication Room and met with a Med Tech who supervised and dispensed medication. Med Tech informed LPA that all residents have at least a 30 day supply of medication. Storage: LPA observed a storage room with sufficient emergency food and water supplies. LPA also observed a locked maintenance room with cleaning supplies. LPA observed an additional, locked storage room on the second floor designated for PPE. Inside, LPA observed adequate supplies of surgical masks, N95 masks, gowns, gloves, and sanitizer. Kitchen: LPA observed menus outside of the kitchen and dining room. Menus applied to typical and diabetic diets. The kitchen floors and surfaces were clean, and all food was sealed and labeled. Cleaning supplies remained by the dishwashing area and were not stored with food. The dining room contained tables with two chairs at each table. All tables were at least 6 feet apart and had hand sanitizer readily available. The dining room also had COVID-19 signs related to social distancing, cough etiquette, and masking requirements. LPA conducted exit interview and issued report.