Routine inspection·July 23, 2021

Licensing Program Analyst (LPA) Nicole Spencer conducted an unannounced annual inspection visit focusing on the Infection Control Domain. LPA Spencer met with assistant administrator Cynthia Flores and administrator Lisa Pham and explained the purpose of today's visit. This three-story residential care facility for the elderly (RCFE) is licensed at a capacity of 160. LPA conducted a physical plant tour and inspected the entrance screening area, dining room, kitchen, ten (10) resident rooms/bathrooms, two (2) isolation/quarantine rooms, medication room, and PPE supply closet. The following was observed: A universal screening area consisted of thermometer, screening log, and hand sanitizer was present. COVID-19 signage was placed in the entrance lobby and several areas of the facility. There was a sufficient supply of 2-day perishable and 7-day non-perishable foods. Sharps and chemicals were stored in kitchen and inaccessible to residents. Facility maintained a 30-day supply of PPE. Ten (10) resident bedrooms were observed and had all required furniture including bed, dresser, chair, lamp, night stand and covered trash can. Hot water temperature was measured and was between the required 105-120 degrees Fahrenheit. Centrally stored and locked medications were reviewed. Facility maintained 30-day supply of meds. Smoke detectors/carbon monoxide detectors were tested on each floor and were functional. All fire extinguishers fully charged and recently serviced in March 2021. Five (5) resident files were reviewed and physician/dentist contact information was missing for three (3) out of five (5) residents. Five (5) staff files were reviewed and all files contained health screening, criminal record clearances, and required trainings. There were no deficiencies were cited at this time. An exit interview was conducted and a copy of the report was provided.