Queen of the Angels Assisted Living Inc.

Based on record review, the licensee did not comply with the section cited above in which 3 out of 6 residents are receiving hospice services which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, , LPA did not observe any fire drill documentation/log book in faciltiy which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, LPA observed the bathroom in Bedroom#1 and the hot water was not working which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on which record review, LPA was not able to review the administrator file in the facility during the inspection which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA did not observe S1 and S2 has the health screening and chest x ray result in their personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA observe R1 to R4 do not have any updated Needs and service plan in residents' files which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA was not able to review the updated liability insurance policy during the inspection which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the facility does not have an updated Emergency Disaster Plan in place, the last one was updated back in 2010 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the facility does not have any infection control plan in place which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA did not observe R3 has any physician report in resident's file since admitted to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA observe R2 did not have an updated physician report and last one was conducted in 2018 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA did not observe any record for facility drill that conduct at least quarterly for each shift which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on the record reviewed, LPA did not observe any updated Administrator Certificate in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA observed Resident#1-#5 all missing different docuements including pre-appraisal, resident's appraisal, admission agreement , physician report which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, LPA did not observe any staff training for resident's right which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA did not observe any training hours for administrator as administrator file was not maintained in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's observation, LPA observed the bathroom#1 and #2 -hot water faucet , the right sink near the toilet are not working.

Based on record review, LPA observed the administrator file was not located in the facility and LPA was not able to review administrator certificate and health screening.

Based on LPA's observation, LPA observed the bathroom#2 hot water temeperature was measured at 78.5 degrees F.

87468.1 Personal Rights of Residents in All Facilities(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Upon entry into the facility, Staff #1 did not provide LPA with a temperature check, did not ask LPA to sign in or wash or sanitize hands. Witness also indicate that during an unannounced visit to the facility on 12/17/21, staff neglected to provide witness with COVID-19 screening and symptoms check.