Routine inspection·November 9, 2021

Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPAs Colvin and Mixon met with Administrator Emely Rodriguez and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Emely Rodriguez, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. LPA Colvin was unable to locate a copy of the facility's Mitigation Plan at the Riverside Community Care Licensing (CCL) office, so Administrator Rodriguez emailed LPA Colvin a copy during today's inspection. LPA Colvin inspected three resident bathrooms. In all three bathrooms, there was minimal (#1) or no (#3 & #12) hand soap, paper towels, or hand sanitizer. This included the locked storage in the bathrooms, as staff must assist residents with hand washing due to the facility being locked Memory Care. LPA Colvin will be citing a deficiency as it is a requirement for residents to have items necessary for hygiene. LPA Colvin recommended to the Administrator that a hygiene "kit" be kept in each resident room in their locked storage in the bathroom. This "kit" could consist of" soap, paper towels, and hand sanitizer, and staff can unlock it and lock it back up after assisting the resident. Deficiency cited. LPA Colvin additionally observed that the trash cans in the residents' bathrooms did not have lids. PA Colvin will be issuing a Technical Assistance (TA) Advisory Note instead of a deficiency as there is little risk of contamination. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to not be sufficient for a 30-day supply. Administrator Rodriguez opened the facility's shed for LPA Colvin and Mixon, but there were no additional N955 masks or surgical masks in the shed. LPA Colvin will be issuing a TA Advisory Note instead of a deficiency as it is recommended that the facility maintain a 30-day supply of PPE at all times. LPA Colvin went over the various recommended training for facility staff with Administrator Emely Rodriguez in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Emely Rodriguez informed LPA Colvin that at this time staff have not been fit tested, but that the Licensee was purchasing a machine to conduct fit testing for all staff of each facility. A TA Advisory Note will be cited due to CCL recommendation for all staff to be fit tested for N95 masks. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, most residents have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. Additionally, CalOSHA also requires staff to be fit tested for N95 masks if staff will be using N95s and providing personal care to residents who are positive for COVID-19. LPA Colvin inquired about if the facility is still conducting COVID-19 surveillance testing of their unvaccinated staff members. Administrator Rodriguez informed LPA Colvin that the majority of their staff is vaccinated, but that they are conducting weekly testing of unvaccinated residents. In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Rodriguez confirmed that staff are continuing to monitor residents’ symptoms during medication pass, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility. LPAs Colvin and Mixon additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions. LPA Colvin inquired about staff and residents wearing masks in the facility, as LPA Colvin observed all staff to be wearing face coverings, but several residents in the dining room were not. Administrator Rodriguez informed LPA Colvin that the majority of residents are vaccinated, and staff still encourage them to wear masks, but some refuse. LPA Colvin acknowledged that the facility cannot force residents to wear masks but can only encourage them to do so. An exit interview was conducted with Administrator Emely Rodriguez and a copy of this report, LIC809D, appeal rights, and LIC9102 TA Advisory Notes were provided.