Routine inspection·October 21, 2021

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with emphasis on infection control. LPA met with staff Yolanda Bacani and Teodora Almagro. Administrator Chandler Ramas was phoned by staff and arrived during this visit. LPA toured the facility inside and out. The facility has no bodies of water. The facility has a charged fire extinguisher, operating smoke alarms, and carbon monoxide detector. Cleaning supplies, medications, and sharps were kept in a safe and locked place. Staff office is located in the garage, where cleaning supplies are kept as well. Medications were kept in a locked cabinet. Sharps were stored in a secured area. Resident bedrooms had the required furniture and sufficient lighting. Facility had a supply of additional linen and hygiene items. LPAs observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, residents, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents. During the tour, LPA observed that Staff 1 (S1) has a criminal record clearances but was not associated to the facility. This poses an immediate health & safety risk to the residents in care. LPA were informed that S1 has worked at this facility since 10/15/21. A civil penalty of $500 was assessed on 10/21/21. A technical advisory was issued as LPA observed that the facility does not have at least a 30 day supply of personal protective equipment (PPE), specifically surgical masks/respirators. However, Administrator Ramas arrived with several boxes of surgical masks. Refer to LIC809D for deficiency cited. An exit interview was conducted where this report, LIC811, LIC809D, LIC421BG, and appeal rights were discussed and provided to administrator Ramas.