Routine inspection·February 15, 2023

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. The purpose of the visit was explained to Administrator David Kim. There are 10 residents ages 60 and above [ 6 ambulatory, 3 non-ambulatory, & 1 bedridden]. A Dementia waiver and an approved hospice waiver for 6 residents is in place. The last fire emergency drill was conducted on 2/6/2023. The last fire Inspection was completed on 8/29/2022 by Eminent Fire Protection. Administrator certificate expires 3/9/2024. OBSERVATIONS Infection Control: COVID-19 Infection Control Practices and signs were observed in the main entrance and restrooms. A visitor sign in station was observed outside the main entrance. Per Administrator, visitors are no longer being screened due to public health order changes in 2022. Visitors are screened by staff only if needed. Staff wear masks. Residents do not wear masks due to health and cognitive issues. Sufficient supply of Personal Protective Equipment (PPE's) was observed. The facility has a contingency plan for back-up staffing if needed. The facility sub mitted a COVID-19 Mitigation Plan. An Infection Control Plan (ICP) has not been submitted. Submit the ICP as soon as possible. The plan should be reviewed and updated as necessary. Administrator has agreed to submit their Infection Control Plan by [up to 60 days from inspection]. Medications: 30-day centrally stored resident medications were observed. *See LIC 809C for report continuation. Physical Plant: The facility is a single story building consisting of 11 resident bedrooms, 7 bathrooms, living room, dining room, tv room kitchen, indoor patio, laundry room, two (2) shaded patio areas, and detached garage. The majority of resident beds did not have mattress pads. Administrator put mattress pads on all beds during the visit. The auditory alarm in the main entrance door was turned off. Administrator immediately turned it on. Eleven (11) resident rooms were inspected. Rooms 1 & 2 are presently being used as living quarters by Licensee. Administrator was advised to update and submit to Community Care Licensing the updated Plan of Operation/Program Design and facility sketch to reflect the changes in facility operation. Food Service: Sufficient food supply is stored in the kitchen and outdoor food storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Resident Files: Three (3) residents are in enrolled in hospice and one (1) resident is bedridden. Staff Files: Criminal Background Clearance was checked. Liability Insurance: Proof of liability insurance was provided. It expires 12/31/2023. A technical advisory was issued pertaining to Infection Control Plan. Deficiencies were cited Exit interview was conducted with Administrator David Kim . A copy of the report and appeal rights was issued.