Routine inspection·July 11, 2023

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to the Director of Health Services Emyrose La Cresta, and the Administrator Liyon O’Quinn arrived shortly thereafter. There are currently one hundred seventy-nine (179) residents who reside within the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility has Physical Plant/Environment Safety: · The contains multiple buildings on its campus including the Administration Building, the Dining Hall Building, Lietzell Hall, Margaret Hall, Kingsly Manor Care Center, and the Whitehouse. It is licensed for a capacity of 285 Ambulatory and 14 Non-Ambulatory residents. It consists of five (5) total buildings that house residents, a dining room, a kitchen and multiple private and public restrooms throughout the facility. Most of the buildings that house residents held water temperature readings that were within the 105 – 120 Degrees F range, however the two (2) restrooms within the White House measured at 140 Degrees F and 126 Degrees F for the Resident Husband’s and Wife’s restrooms respectively. The Maintenance Supervisor arrived at the facility and was able to correct the water temperature during the visit and explained that the heat was set too high accidentally. The facility’s main laundry for residents is located in the basement of Lietzell Hall, and the 6 th floor of Lietzell Hall contains the facility’s rooftop patio, movie theater, and main activity room. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility multiple fully charged fire extinguishers in each floor of the resident’s halls in their laundry room. · Water temperature readings measured between the required 105 - 120 degrees Fahrenheit in most buildings except the White House which was corrected during the visit. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for 285 Ambulatory and 14 Non-Ambulatory residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · A total of one hundred and one (101) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Two (2) staff files were reviewed for criminal background clearance and training. · Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training. Client Rights/Information: · Physician orders were reviewed in client files. Client Records/Incident Reports: · Nine (9) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. · No restricted Health Care plan required for the clients in the facility. Incident Medical and Dental: · All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file. · Staff training was on file. LPA was not able to complete the Annual Inspection at this time and will be returning to complete it.