complaint·October 18, 2022

Continue from LIC9099 Initial covid positive case was reported to CCL on May 26, 2022. Sixteen memory care residents and three staff members tested positive on May 25, 2022, during routine weekly testing surveillance. During the outbreak, the facility received guidance from the COVID-19 Site Assessment Nurse, with the Department of Public Health Infectious Disease Control. In addition, as it was standard protocol to mitigate the spread of Covid-19 during an outbreak, CCL staff conducted daily monitoring with the facility’s Infection Control Lead to provide infection control guidelines and technical assistance. On June 1, 2022, the Department conducted a visit at the facility to commence the complaint investigation which included a tour of the facility. During the tour, it was observed the facility had one central entry point for universal entry screening and routine symptom screening was initiated at entry for all staff and visitors. It was observed that signs were posted at facility entrance and signs throughout the facility to promote face covering, hand hygiene, cough/sneeze etiquette and physical distancing. All isolation rooms were properly identified with signage and Personal Protective Equipment (PPE) supplies were stored outside the isolation rooms. Staff were observed wearing N-95 respirators and in full PPE gear when entering the isolation rooms. No violations were observed during the tour. Review and reconciliation of Covid-19 positive line list, resident roster and room accommodations indicated that Covid-19 positive residents were in isolation by themselves in their own rooms. In cases when the residents were sharing rooms, they were sharing with another Covid-19 positive resident. However, records review and staff interviews disclosed one resident that tested positive for Covid-19 on May 25, 2022 shared a room with a resident that tested negative for Covid-19 on the same day. Both residents were asymptomatic and fully vaccinated. The residents remained in the same room for three days, which resulted in the non Covid-19 resident being exposed to Covid-19 during the infectious period. Review of facility room availability indicated there were four (4) empty rooms available for isolation on May 25, 2022. When staff realized the oversight, the Covid-19 positive resident was immediately moved to an empty room on May 28, 2022, and subsequently cleared from quarantine on June 3, 2022. The non-Covid-19 resident did not test positive for Covid-19. During interviews, staff indicated they were busy managing the Covid-19 outbreak and failed to isolate the Covid-19 positive resident to protect the non-Covid-19 resident. Review of the facility Covid-19 infection control plan for shared rooms outlined the following protocols: (1) Do not transfer a resident with negative result in a room with Covid-19 positive resident, and (2) Upon finding positive results immediately try to separate shared room residents unless both are positive or both display symptoms. Continue on LIC9099C Continue from LIC9099C The Department has investigated the above-mentioned allegation and has found that there was sufficient evidence to corroborate the allegation. Therefore, this allegation is deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A plan of corrections was developed with Administrator, Liz Reyes. An exit interview was conducted with Administrator, Liz Reyes, to whom a copy of this report, Deficiency Report LIC9099D, and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.