Routine inspection·June 24, 2022

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Executive Director Elizabeth Spencer and informed them of the reason for the visit. The LPA and the Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Common Areas: The facility is a three-story building. There are resident rooms on all three floors. Upon entry to the facility, there is a central entry point for symptom screening and temperature checks for residents, staff, and visitors. Staff were observed wearing appropriate face coverings throughout the visit. In addition, the LPA observed hands-free hand sanitizer interspersed throughout the common grounds. There were no obstructions or tripping hazards throughout the facility. The facility maintains a comfortable temperature at 73 degrees. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair. Outside areas: The LPA toured the outside area of the facility and the courtyard. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a pool for resident usage with appropriate fencing and it was locked at the time of the visit.. Parking is available for residents and visitors. Area is maintained clean. Kitchen: Dining is located on the third floor and was observed to be clean and sanitary at the time of the visit. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. The menu was posted and the facility offers an alternate menu. Facility uses Sysco Foods for food deliveries, and delivery takes place twice a week. Snacks and beverages are available for residents in the Bistro area on the 2nd f loor. Common Restrooms: The LPA observed common restrooms on all three floors. The LPA informed the Executive Director that signs promoting good hand hygiene should be placed in all common restrooms in the facility. However, all restrooms were fully stocked with soap and paper towels. Infection Control: During today’s visit, the LPA spoke with the Executive Director regarding the community's infection control practices. The LPA encouraged the Executive Director to create a centralized location with COVID-19 signage that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. However, the community previously had the appropriate signs posted for resident review prior to the cosmetic changes made on the second floor. The community has an adequate supply of Personal Protection Equipment (PPE) and is able to obtain additional supplies. The community's cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. If needed, the facility has the capacity to designate isolation zones or can isolate persons in their room if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The Infection Control Plan was submitted timely. The community's policies and procedures pertaining to infection control were adequate. No deficiencies observed at this time. Exit interview conducted. A copy of the report was issued.