Routine inspection·October 23, 2022

On 10/23/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Khatera Bahadory. LPA explained the purpose of today’s visit. The facility is licensed to serve (184) of which (178) non-ambulatory and (6) bedridden elderly adults ages 60 and above. The facility is approved for (6) hospice residents. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: Eighty (80) resident bedrooms with a bathroom in each unit, four (4) public bathrooms, a reception area, a beauty shop, an activity room, a kitchen, a dining, a laundry room, a medication room, three (3) outside patios, and offices. LPA toured the physical plant with Bahadory. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #109; #114; #111: #236; #239 and call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature 105.0 degrees F. The room temperature ranged from 74 degrees F. LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. Several working landline phones are available on-site. A review of (8) residents' service files (R1-R8) and (7) staff personnel files (S1-S7) and Medication Administration Records (MAR) were maintained in order. A review of staff CPR/First Aid Training are current. A current liability insurance effective 08/06/22 - 08/06/23 was on file. ( Evaluation Report continues on LIC 809-C) DEFICIENCY: At 12pm, LPA identified hazardous paint chemicals stored in unlocked cabinets in the dining room and beauty salon area accessible to residents in care. INFECTION CONTROL: LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of residents' and staff COVID vaccinations was conducted for (R1-R8) and staff (S1-S7). The facility has provided CCLD with an approved Mitigation Plan and has submitted an Infection Control Plan 2022 to CCLD. A 2022 Monkey Pox Inspection Control was submitted to CCLD as well. Deficiency is issued and an exit interview is conducted with Khatera Bahadory. A copy of this report is provided along with the appeal rights.