Routine inspection·January 25, 2022

Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced required annual inspection to the facility. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Carolina Garcia'Trejo and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The dining room furniture was observed to be in good condition. Per administrator they are currently not using the dinning room in Assisted Living as a precaution. BEDROOMS: The LPA observed randomly selected resident rooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting. LPA observed carpeting stained/dirty and blind broken in residents rooms. A discussion was held with the administrator who stated they will be shampooing the carpets once dinning room is opened. Administrator also agreed to inspect all resident rooms, create a maintenance log to document all rooms that need repairs. She will then ensure that maintenance completed the required repairs. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms are sufficiently stocked with hand liquid soap and paper towels. COMMON SPACES: Common areas include the dining room, activity room and patio. In the common areas, walls, flooring and furniture were checked for cleanliness and good condition. The fire extinguisher in the hallways were fully charged and was last serviced 3/2021. Required postings were observed throughout the common hallways in Assisted Living but were not posted in memory care. Administrator agreed to post the required postings in Memory Care. Record Reviews: LPA conducted review or resident and staff files from approximately 10:45 am to 1:00 pm and observed the following. Licensee does not have current physicians report for 7 out of 7 resident who have a diagnosis of Major Neurocognitive disorder. Licensee does not have current/completed hospice care plan for 7 out of 7 residents who are currently receiving hospice services. A discussion was held with the administrator on 10/20/2021 regarding obtaining current, complete hospice care plans for all residents. 2 out of 7 hospice residents utilize full bed rails however licensee does not have hospice care plan that indicates the need for the full rails 5 out of 7 residents are utilizing half rails however licensee does not have physician orders to utilize the rails. Licensee is retaining bedridden residents in rooms that do not have bedridden fire clearance. (Rm 201, 12 A & 12 B, 229 A) At 2:24 pm LPA spoke with the administrator regarding ambulatory status of for the 24 hospice residents. Administrator informed the LPA that 8 of the resident are unable to independently reposition in bed and are considered bedridden. 4 of the 8 residents are residing in rooms that do not have bedridden fire clearance. Staff records were reviewed and observed to be complete with the required documentation. All staff have criminal record clearance and are associated to the facility. While reviewing staff files LPA observed 6 out of 8 staff do not have required training. 2 out of 2 newly hired staff training verification was not properly documented. Staff do not have current first aid/CPR training. A discussion was held with the administrator who stated she will review staff files and schedule training for all staff who do not have the required annual training's, including first aid/CPR, Also during today's visit while conducting a tour of the facility at 1:05 pm LPA was informed by the administrator that beginning of January they had 2 residents who tested positive for COVID. LPA was informed that incident reports were faxed to the Woodland Hills South Regional office, however while reviewing the report LPA observed that the fax number was not for the department. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) in storage and the facility is able to obtain additional supplies as needed. The LPA observed resident and staff temperature logs, visitation screening questions, and cleaning log. The facility’s cleaning protocol is sufficient. Staff and residents were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA and Administrator discussed the recent PIN as it relates to visitation and staff vaccination requirements. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. This facility keeps track of vaccination rates for current staff. The facility’s policies and procedures as it pertains to infection control are adequate. Prior to the completion of the visit LPA requested for the following to be submitted. Documentation to change the administrator of the facility to Carolina Garcia'Trejo. Copy of current Liability insurance. Exit interview conducted. Copy of Report citations and Civil Penalties emailed to the administrator.