Routine inspection·February 23, 2022

At 1:45 p.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff, Elya Poghosyan. At 2:06 p.m., the Administrator arrived at the facility. This annual had a specific emphasis on infection control practices and procedures. At 2:18 p.m., 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. COMMON AREAS: LPA observed common area to be relatively clean and properly furnished. LPA observed the fire extinguisher to be fully charged and purchased on 06/01/2021. Flashlights were observed throughout the facility. Signs are posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing. At 2:34 p.m., fire alarms and carbon monoxide detectors were tested and functioning properly. BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with a grab bar and non-skid mats. At 2:35 p.m., hot water measured at 109.9-degree Fahrenheit. Night lights were present in the hallways and passages. OUTDOOR SPACE: At 2:21 p.m., LPA observed the backyard, which has a covered outdoor area for resident use. There is a gate at the front of the facility designated for an emergency exit. Passageways were free and clear from obstruction. Continued on LIC 809-C. Contiued from LIC 809. KITCHEN: At 2:23 p.m., LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 2:33 p.m., hot water measured at 105.2-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen cabinet. STORAGE: The storage room is next to the kitchen. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the storage room. The laundry units are located inside the storage room. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate. Between 2:08 p.m. - 2:18 p.m., LPA conducted Infection Control mitigation module with Administrator. The following recommendations were made: - Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department. No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report will be provided via email.