Post-licensing visit·September 3, 2021

Licensing Program Analyst, Sandra Urena conducted an announced Post Licensing Visit, and an Infection Control Inspection. LPA Urena arrived at the facility at 10:45am, met with Licensee Armine Grigoryan, and explained the reason for the visit. At 12:00 pm, the 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. INFECTION CONTROL: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control signage was visible at entrance. LPA observed that the supply of Personal Protection Equipment (PPE) was limited and not fully available. The facility’s cleaning protocol is sufficient. Bedrooms : At 12:15pm, the LPA observed the residents’ bedrooms have clean bed linens and were in clean condition There is at least one chair, nightstand and sufficient lighting for each resident. Bathroom: At 12:30pm, the LPA observed the bathroom, it had a tub and enclosed shower doors. The tub had grab bars, and a nonskid mat. It was in a clean condition. Paper towels were not available for hand drying. Kitchen: At 12:35 pm, LPA observed the kitchen/dining area. Knives are stored in a locked pantry. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Freezer had a limited supply meat, the supply appeared to be only for two days. Emergency food supply was not available. Emergency water supply consisted of one- 24 cas bottled water, and two gallons of water. Outdoor Area : At 12:45 pm, LPA observed the Outdoor space. A shaded patio is available for residents to visit with family members. Side gate is unlocked. Medications : At 1:00pm the LPA observed that medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Medications were available for three of the four residents residing in the facility. Medication dispensing logs were not available at facility. Licensee stated that Medication Logs were removed by administrator. Record Review: Resident records: At 1:30pm, LPA Urena reviewed residents’ files for current Needs and Service plans, admission agreements, Consent forms, Safeguard for Personal Property/Valuables, TB, Personal rights. Three out of four residents’ files were not available at the facility. The only file available for review had all required documents available, but had an Appraisal/ Needs and Services Plan (1-4 pages) signed by resident, however pages two and three of the appraisals were blank. Licensee stated files were stored with the administrator. Files were not stored locally at facility. Staff records : At 1:45 pm, the LPA conducted a file review of staff for criminal record clearances/associations/and current First Aid. All files had the required documentation. A personnel LIS search revealed six individuals associated to the facility. Two of the associated individuals were present at the facility during today’s visit. Staff have not been fit tested for N-95 masks. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of the report was issued