complaint·November 16, 2021

Interviews with residents 2 out of 6 residents stated to not have visitors. 1 out of 6 residents stated to receive visitors and to have additional visitation sources like video call and 3 out of 6 were not able to answer due to cognitive skills. Interviews with staff 4 out of 6 staff stated facility has a visitation plan which requires visitors to have a negative COVID test and visitors have additional visitation options and 2 out of 6 staff were not aware of visitation guidelines. LPA Flores reviewed visitation guidelines emailed to administrator on August 23, 2021 by corporate office and forward to resident representatives on the same day. Visitation guidelines state visitation hours which must be schedule ahead, "required to be tested on their own prior to coming to the facility (within the last 2-3 days) with proof of negative test results and date of the test... Visitors who are unable to adhere to the core principles of COVID 19 infection prevention should not be permitted to visit or should be asked to leave...If it is not possible to have outdoor visitation then visitation will take place in a designated space that has room for physical distancing and adequate ventilation, if available." Administrator Nirjara Acharya stated facility provides a COVID rapid test for family members that may not have a test upon arriving or are not aware of policy, families are able to take residents out or have outdoor visit if not able to provide a negative COVID test result, and facility offers other visiting options such as window visits, video call, and/or phone calls. LPA reviewed visitation log for 7/31/21 to 9/1/21. Per PIN 21.17.2 ASC dated 5/14/21 Licensees should allow indoor visitation, including in-room visitation, at all times and for all residents, regardless of vaccination status of the resident or visitor. During the visit of 9/27/21 LPA Flores discussed current PIN 21.40ASC with new visitation guidelines. Based on LPA's observations, documents review, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Nirjara Acharya Administrator and a copy of this report, LIC 9099D, and appeal rights were provided. Regarding allegation: Facility is not properly disinfecting facility surfaces. It is alleged visitation room it is only cleaned once a day, not after each visit. Interviews with residents 1 out of 6 residents stated visitors room gets cleaned after each visit, 5 out of 6 resident were unable to answer due to cognitive skills. Interviews with staff 4 out of 6 staff stated visitation room gets cleaned and disinfected after each visit and 1 out of 6 staff stated to not know be aware of cleaning and disinfecting of visitation room. LPA reviewed staff training dated 6/24/21 employee guidelines and mitigation plan dated 1/22/21 states "Clean and disinfect frequently touch objects visitors may use or could have used including ... rooms after each meeting between a visitor and person in care." LPA Flores observed assistant administrator disinfect the visitation area in which interviews were conducted upon entering the room, no trash or unattended items were observed. Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Exit interview was conducted with Nirjara Acharya Administrator and copy of this report was provided.