Routine inspection·October 25, 2022

Licensing Program Analysts (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the front door and at the entry point. There is one entry point designated where sign in procedures and screening occur. The staff are symptom/temperature screening visitors upon entry into the facility. LPA observes that all staff are wearing face masks. LPA is informed that there are no positive cases of Covid-19 at this time. There are four (4) residents present at the time of the visit, two of which are receiving hospice services. LPAs conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and a 30 day supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in infection control. The facility continues to monitor client regularly for any changes in condition, and notify the client's physician and emergency personnel in the event the client presents any COVID-19 symptoms. Emergency food supply is in place. LPA inquired about fit testing and found that the employees have not been fit tested for N95 respirators. Technical assistance provided during this visit. LPAs observed three of four resident beds are outfitted with full bed rails. Two of three residents are receiving hospice services and have a careplan including full bed rails in place. One of three residents with full bed rails are not on hospice. Having full bed rails is a risk to the health and safety of this resident. Based on observations made during today’s inspection, the following is being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.