Routine inspection·October 14, 2022

License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by Staff Walter Paredes. Staff contacted Administrator Charleen Vierra who arrived during the inspection. There is a total of 20 residents with 6 residents on Hospice and 13 residents with Dementia. LPA toured the facility on 10/14/2022 at 10:45AM with staff Walter, Chef, Aide. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 6/21/2022 at the time of the visit. Facility smoke detectors are hard wired and sound directly to Stanley Security which notifies Fire and Police Departments. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 8/31/2022. LPA observed Carbon monoxide detectors that were found to be operational during the visit. There is a backup generator that powers many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured 106.7, 109.2, 113.1, 113.5, 118, & 122.7 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in resident’s bathrooms while touring facility. (see LIC 809D). Facility serves residents with dementia and has special care plan of operation and programming. 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 at the time of the visit. Food is available for residents any time of the day. There is a daily activity schedule for residents: scrabble, live music, balloon basketball, & salsa. Toxins are stored in a locked housekeeping closet and under the kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Continue to LIC809-C Infection Control: Facility has submitted a mitigation program plan that was approved. Posters have been placed at facility. Facility has PPE supply stored in the upstairs closet and downstairs in the kitchen and administrator’s office. Residents’ medications are centrally stored and locked in the kitchen. Facility has a 30-day supply of medication for residents. Staff had required PPE training and N95 Fit Testing. LPA reviewed Licensing Information System (LIS) with Administrator who stated that is correct and updated at this time; no need to change any of the information. Disaster Drills have been conducted quarterly with the last one being conducted on 8/16/2022. LPA advised facility to contact Marin County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA was presented with proof of current CPR & 1 st Aid certification for staff. Administrator Certificate is for Charleen Vierra 6053696740 Exp. 10/2/2023 All staff have received COVID booster vaccinations. Licensee has not submitted the infection control plan. The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agrees to submit the Infection Control Plan by December 14, 2022”. LPA is issuing a Technical Assistance (see LIC 9102TA). While at facility LPA was provided a list of staff currently working. Staff (S1) was identified by LPA as not having fingerprint clearance and has worked at facility since 9/3/2022. Immediate Civil Penalties are being assessed in the amount of $500 due to staff S1 not having background check clearance and not being associated to the facility. *****Total Civil Penalties issued today in the amount of $500.00 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. Continue on LIC 809-C2 LIC 809-C 2 Appeal of Rights Given LPA Hansen is requesting Licensee to update and submit the following documents by 10/28/2021: Copy of Annual Sprinkler Inspection LIC 308 Designation of Responsibility LIC 309 Administrative Organization Articles of Corporation LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Resident’s Copy of current Certificate of Liability Insurance