Routine inspection·October 7, 2021

Licensing Program Analysts (LPA) Galarza and Jewel Baptiste conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Tyler Cheney and Wellness Director Ruby Magao and explained the purpose of the visit. The facility is a 5 story story building located in a residential neighborhood that is licensed for 85 adults 60 and over approved for 85 non-ambulatory, of which 9 may be bedridden. The facility has a hospice waiver for 20. The facility consists of 69 rooms, activity room, dining room, kitchen, Wellness office, laundry room, and an outdoor water fountain. The last fire drill was conducted on 9/3/2021. The following were observed/inspected: The interior and exterior physical plant was inspected. Twenty nine (29) rooms were inspected. COVID-19 Infection Control Practices and signs were observed in the entrance, some common areas hallways, but not in the public bathrooms and resident bathrooms. Signs are not posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Furniture was observed to be at least 6 feet apart. Each client's room is designated as a COVID-19 solation room if needed. All staff were observed wearing mask. Six (6) centrally stored resident medication records were reviewed. Medication errors were observed. The residents were observed wearing masks. Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. A posted Emergency Disaster Plan was observed. Facility has sufficient supply of Personal Protective Equipment (PPEs). Resident's physician reports were reviewed during today's visit. Deficiencies were cited. See LIC 809D. Exit interview was conducted with Administrator Tyler Cheney and Wellness Director Ruby Magao. A copy of the report was provided.