Routine inspection·June 7, 2022

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Luzviminda Bulosan and explained the purpose of the visit. There are 3 residents ages 60 and above. The facility has a Dementia waiver, and a hospice waiver for 2 residents. Facility is a single story home located in a residential area consisting of 4 bedrooms (2 shared & 2 private), living room/dining area, kitchen, outdoor covered patio area, shed, and laundry area located in the backyard porch area. There is a detached garage in the rear of the property presently being used as storage and staff "resting area". The last emergency disaster drill was conducted on 5/17/2022. Administrator certificate expires 9/25/2022. The following was inspected and observed during the inspection: The interior and exterior physical plant was inspected. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Facility has an approved COVID-19 mitigation plan. LPA was screened upon entry by staff. Room # 4 is designated as the COVID-19 isolation room if needed. Three (3) centrally stored resident medication records were reviewed. Due to cognitive impairment residents in care do not wear masks. Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed. A posted Emergency Disaster Plan was observed. Sufficient supply of Personal Protective Equipment (PPEs) was observed. Both exterior side gates had locks on the exit doors. The locks were immediately removed. A couch, foldable beds, bed, and staff personal belongings were observed. Administrator stated it is "sometimes" used by Administrator/Licensee & spouse to rest between shifts. The plan of operation staffing plan and facility sketch does not indicate the garage is to be used as a staff room. "Between 10 pm and 6 am, at least one staff person shall be awake and on duty if any resident with Dementia .... require night supervision." Deficiencies were cited. See LIC 809D. Exit interview was conducted with Luzviminda Bulosan . A copy of the report and appeal rights were issued.