complaint·October 3, 2022

LPA asked S1 why a face mask was not in use, and S1 responded it was because S1 forgot to put it on upon LPA's arrival. S1 put on a face mask when LPA asked. As S2 arrived to the facility, appropriate PPE was observed to be worn. S2 was asked about the policy of staff wearing PPE in the facility, and admitted that S1 does not always wear face mask as S1 is live-in staff. LPA informed S1 and S2 that PPE must be worn by staff inside the facility at all times, as that is current CCLD and lcoal Department of Public Health (DPH) guidance. Regarding Allegation: Staff are not following the infection control practice as required. LPA Maldonado reviewed facility file and determined that a mitigation plan was submitted and approved on 06/04/21. Upon arrival at the facility, LPA was not screened for COVID-19 symptoms, until LPA asked S1 why a screening was not initiated. S1 stated that the screening was not initiated as S1 forgot, due to the LPA's unannounced visit. S1 was reminded that CCLD guidance is to screen all residents, visitors, and staff upon entry to the facility and upon return from any outing. LPA observed COVID-19 sign-age throughout the facility promoting mask wearing, hand washing, and social distancing. There was also sign-age on proper donning and doffing of PPE and choosing the right face mask. LPA observed the PPE supplies in the facility and had less than 30 day supplies available. LPA observed hand sanitizer available in all resident rooms, hand soap in the bathrooms, and paper towels for hand drying. LPA reviewed files for S1-S5 for required training and In-Service training regarding COVID-19 infection control practices. LPA observed 4 out of 5 staff files to be missing COVID-19 infection control practices training certification. LPA asked S1 and S2 for records of staff and residents daily symptom screenings and they stated records are not kept, however daily symptoms are checked for all residents. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. California Code of Regulations, Title 22 are being cited on the attached LIC-9099D. An exit interview was conducted with assistant house manager Samson Deles and RN Shanelle Hurtado. A copy of this report and appeal right were provided.