Routine inspection·November 15, 2022

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA explained the purpose of the visit to Administrator Diana Bautista and Business Office Manager Andrea Lopez. The last fire emergency drill was conducted in 2021. The last Fire Inspection was conducted on 7/28/2022. OBSERVATIONS Physical Plant: The facility is a three (3) story building consisting of 77 resident rooms and licensed for 114 adults age 60 and over; of which 15 may be bedridden. A hospice waiver for 20 is in place. The 1st floor consists of a lobby, dining room with outdoor courtyard, kitchen, medication room, administrative offices, electrical room, public restrooms, laundry room, 21 resident rooms, shaded outdoor courtyard area, and a Memory Care unit with multi-purpose room, and outdoor courtyard. The 2nd floor consists of 28 resident rooms, Bistro area, game room, public restrooms, 2 storage rooms, laundry/housekeeping room, outdoor shaded balcony area, and 2 common areas. The 3rd floor consists of 28 resident rooms, fitness room, theater room, lounge, beauty shop, and outdoor shaded balcony area. Delayed egress is in place in the 1st floor Memory Care unit. There are evacuation chairs on 2nd and 3rd floor stairwells to be used during an emergency as a path of egress from the facility to safety were observed. Twenty-two (22) rooms were inspected. *See LIC 809C for report continuation. Infection Control: Visitors are screened in the main entrance lobby area. A sign-in sheet, thermometer, and hand sanitizer were observed. Hand sanitizer were observed in common areas. Residents are encouraged to wear masks. COVID-19 Infection Control Practices and signs were observed in the main entrance, common areas, and public restrooms. Adequate supply of Personal Protective Equipment (PPE's) was observed. The facility has a contingency plan for back-up staffing if needed. An Infection Control Plan & Monkey Pox Plan were submitted to CCL. Medications: Ten (10) centrally stored resident medication records were reviewed. Residents (R1-R4) were missing medications ordered by MD. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, 7-day non-perishables, and emergency food supplies. Note: The Dining Services Director has an expired food handling certificate. Resident Files: Medication Administration Reports were reviewed. There are a total of 16 residents receiving hospice services. There are a total of 7 residents receiving home health services. Staff Files: Criminal Background Clearance was checked. Liability Insurance & Surety Bond: Proof of liability insurance and Surety bond was provided. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were issued.