Routine inspection·September 29, 2021

On 9/29/2021, Licensing Program Analyst(LPA) Murial Han and LPA Komal Charitra conducted an unannounced annual inspection. LPAs observed COVID-19 signs posted by the entrance. LPAs were greeted by the Director of Behavioral Health Center, Linda SIms and the Administrator, Adela Morales joined shortly thereafter. LPA Han and LPA Charitra explained the purpose of the visit and LPAs were screened at the front entrance. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies (facility has designated 2 private rooms, 1 semi-private room, 1 shower room and 2 bathrooms for the quarantine and isolation purposes when needed), PPE supply and the environmental cleaning supply are adequate (the Director of Behavioral Health Center reviews the PPE inventory on a daily basis and replenishes the supplies when needed), bathrooms are equipped with soap and paper towels, however, there are no hand-washing signs posted; some signs are posted through-out the facility such as social distancing in different languages, cough etiquette, etc; trash cans are observed to have foot operated lids. Medications, toxins and sharps are stored appropriately and inaccessible to resident, and a comfortable temperature is maintained, lighting is sufficient for comfort. There were signs/stickers on the floor in the elevators and thought-out the facility to remind everyone to maintain social distancing. Residents were observed to be maintaining social distancing during mealtime and in the TV room. LPA Han requested for the following documents to be submitted by 10/4/2021 by noon: - Proof Administrator Certification was submitted, - LIC 500 - LIC 402 - LIC 308 - Review LIC 555 LPAs discussed the following recommendations during the inspection: - Post additional COVID-19 signs in the hallways, the common areas/dinning rooms, the staff lounge, the bathrooms, and the shower rooms. - Post hand-washing signs above each sink. - Remove 2 chairs from the table in the staff lounge and mark off one of the seats on the double seated couch to ensure social distancing is maintained. No deficiency cited today. This report is reviewed and discussed with the Administrator and the Director of Behavioral Center and a copy is provided.