complaint·October 20, 2022

On February 3, 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. Visitors were required to wear a mask and sign-in at the reception area. It was observed that signs were posted at facility entrance and throughout the facility to promote face masks, hand hygiene, cough/sneeze etiquette and physical distancing. All staff present at the facility on February 3, 2022, were observed wearing surgical face masks. Although, it was a recommendation not mandated per Title 22 regulations for residents in assisted living to wear face coverings. The majority of the residents were observed wearing either a surgical mask provided by the facility or their own face covering when they were walking around the facility. The few residents that were not wearing a face covering, when staff provided reminders the residents put their face coverings on upon request. Interviews with staff, residents and outside sources consistently indicated they had no concerns regarding facility COVID-19 infection control protocols. Direct care staff in memory care indicated that residents that tested positive were placed in isolation for the recommended quarantine period. Most memory care residents did not wear face coverings due to their cognitive medical condition; they would take off the masks as they did not understand COVID-19 infection control protocols. In addition, some memory care residents had face covering exemptions due to respiratory conditions. In an effort to mitigate the spread of COVID-19 during an outbreak in July of 2021 and again in March 2022, CCL staff conducted daily monitoring with facility’s Infection Control Lead to provide infection control guidelines and technical assistance. In addition, on May 23, 2022, CCL conducted an Infection Control Inspection which resulted in no violations of Title 22 regulations. Based on observations, interviews with staff, residents, and outside sources, it was determined the facility was in substantial compliance with and implemented their infection control practices as outlined in its COVID-19 Mitigation Plan (LIC 808). Therefore, this allegation is deemed to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with RSD, Robert, to whom a copy of this report, and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.