Routine inspection·November 18, 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 Licensee/Administrator Conchita Diata 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 Licensee/Administrator Conchita Diata, who LPA Colvin found to be successfully incorporating several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels. 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. Licensee/Administrator Conchita Diata informed LPA Colvin that they have been unable to purchase supplies online, which is why they do not have any N95 msks, isolation gowns, or face shields. 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 will additionally coordinate to have supplies brought to the facility ASAP to ensure they have everything needed on hand in case of a COVID-19 case. Upon entry of the facility, LPAs observed that facility staff did not take LPAs temperature or have LPAs sign-in on a sign-in sheet. LPA Colvin inquired as to if the facility has the Hospcie Nurses sign in and have their temperature taken by staff, and the Licensee stated that no they do not. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note instead of a deficiency (for lack of screening & sign in)as it is only a recommendation by the Department at this time for facilities to screen all visitors prior to admitting to facility, as well as utilizing a sing-in sheet. The Licensee was advised to begin incorporating these recommendations as they may become regulations in the future, for which the facility may be cited deficiencies for. LPAs additionally inquired with the Licensee as to if the front door (which LPAs entered through) is the only entry way being used at this time, as recommended for infection control. The Licensee stated that Hospice goes through another door by the garage, as it is closer to the resident's (R1) room, and they do not need to walk throughout the entire facility. A TA Advisory Note will be cited due to Community Care Licensing (CCL) recommendation for a single entry and exit point to be used. LPA Colvin went over the various recommended training for facility staff with Licensee/Administrator Conchita Diata 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 Licensee/Administrator Conchita Diata informed LPA Colvin that at this time staff have not been fit tested. 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. LPA Colvin provided Licensee/Administrator Conchita Diata with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. LPA Colvin inquired about if the facility is still conducting COVID-19 surveillance testing of their unvaccinated staff members. Licensee/Administrator Conchita Diata informed LPA Colvin that all staff are vaccinated, so continued testing is not required. 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. Licensee/Administrator Conchita Diata confirmed that staff are continuing to monitor residents’ symptoms, and that if someone in the facility tests positive for COVID-19 that all staff and residents will be tested at least twice to confirm no additional positive cases. Additional Items: During LPAs inspection of the facility, LPAs observed one resident (R1) at the facility, whom the Licensee stated is "bed-bound". LPA Colvin inquired as to if R1 was "bed-bound" or bedridden, specifically, if staff needed to turn R1. Licensee confirmed that staff are required to turn R1. LPA Colvin observed that the facility does not have approved fire clearance for any bedridden residents, and is only approved for non-ambulatory. LPA Colvin further confirmed R1's bedridden status through review of R1's hospice records, which state that R1 is bed-bound (only option available other than independent or non-ambulatory) and that R1 requires "full assist" with all Activities of Daily Living (ADLs). The Licensee stated that a previous LPA informed her that so long as a resident is on Hospice they do not require a bedridden waiver. LPA Colvin informed the Licensee that Health and Safety Code 1569.73(h) states that even if a resident is on Hospice, the facility is still required to have an approved Fire Clearance from the Fire Department. Deficiency cited. A violation of a facility's fire clearance comes with an immediate civil penalty in the amount of $500 due to the severity of the violation. A civil penalty for $500 is being assessed during today's inspection. Additionally, while looking through R1's records, LPA Colvin observed that R1's Pre-Appraisal and Functional Capabilities Assessment have not been updated since 2019, at which point R1's needs were very different from what they are today, as observed by it noting R1 is non-ambulatory and not on Hospice. Facilities are required to update these documents as residents' needs change. Deficiency cited. An exit interview was conducted with Licensee/Administrator Conchita Diata and a copy of this report, Licensing Application (LIC200) to apply for an ambulatory status change, LIC809D, LIC421IM, appeal rights, and LIC9102 TA Advisory Notes were provided. Note: The Licensee refused to sign the LIC421IM due to disagreeing with the civil penalty. Noted on the form that Licensee refused to sign.