Routine inspection·May 26, 2022

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by front desk staff who directed LPA to sanitize hands, screen for symptoms, and sign-in on the visitor sheet. Front desk contacted Resident Care Director Loata Taole for the visit. There are 33 residents in care at the facility with 7 on Hospice. At approximately 9:45 am on 5/26/2022, Interim Executive Director, Tony Ibarra arrived at the facility and began the inspection. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/4/2021 at the time of the visit. Fire sprinkler system (Matrix) which is connected with smoke and carbon monoxide detectors was last inspected on 1/18/2022. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in the laundry room cabinet on the first floor. However, Lysol was found in an unlocked cabinet on the second floor kitchenette accessible to residents, along with nail polish remover in R1’s night stand (see pictures, LIC 809-D), which were removed by Administrator during inspection. Dangerous items are kept in the main kitchen or locked in the medication room. However, R2 had a box of razors, nail clippers, and scissors in his bathroom (see pictures, LIC 809-D). All resident’s bedrooms have lighting & appropriate furnishings. In 7 out of 9 residents bathroom faucets hot water temperature measured between 121.8 degrees F and 124.5 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees (see LIC 809-D). Administrator contacted facility service vendor during tour to adjust the water temperature today. Residents’ medications are centrally stored and locked in the medication room on the second floor. Facility has a 30-day supply of medication for residents. Continue on LIC 809-C Infection Control: Facility has submitted a mitigation program plan that was approved on 6/15/2021. Posters have been placed at entrance, and facility has a station at main entrance with electronic temperature reader, sign in sheet, and hand sanitizer designated for visitors and staff. Facility has PPE supply stored on the second-floor locked supply closet. All staff had masks on during this visit. Residents have also available Facetime, Zoom, and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and acquired N-95 fit testing. LPA reviewed Licensing Information System (LIS) with Interim Administrator who stated that is all correct and up today at this time. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one conducted on 3/31/2022, the last fire drills 3/31/2022. LPA was presented with proof of current CPR & 1 st Aid certification for staff. Administrator Certificate is for Brittany Karlinski # 6048414740 Exp. 6/17/2022 All staff have received COVID booster vaccinations. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given LPA Hansen is requesting Licensee to update and submit the following documents by 6/15/2022 to SRRO: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 610E-S Supplemental Emergency Disaster Plan for RCFE LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Proof of Liability Insurance