Routine inspection·July 20, 2022

Licensing Program Analyst's (LPA's) Olson conducted an on-site 1 year infection control annual visit to the facility above on 07/20/2022 at 10:00 AM. LPA met with Administrator Douglas Tucker and explained the purpose of the visit. LPA took a physical plant tour of the facility with Administrator from 10:20am-11:30am. The facility has an entry point at the front entrance where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff and visitors wanting to come into the facility. All documentation is kept on file. The entry station has a hand washing station, hand sanitizer along with thermometers. The facility has multiple areas spaced to accommodate as much space as possible for social distancing. The facility has multiple courtyards and outdoor areas for resident use with shade. All equipment and PPE supplies are kept in storage closets. Medications are kept in a locked medication room. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted throughout the campus regarding Covid-19 and infection control. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Continued 809-C Ali Reynoso, Director of Heath Services is in charge of infection control and provides training and education to staff, residents and visitors. If any suspected or confirmed cases of Covid-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other negative individuals until cleared by Health Department to do so. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident isolation. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolated resident room. The facility has proper cleaning and disinfectant policies. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff records are kept in the Human Resource office and resident records are kept in the Wellness Center. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificates are valid. The facility has hardwired smoke and carbon monoxide detectors thorough the facility. Fire extinguishers were charged and last serviced on 10/14/2021 in San Rafael, Sierra Madre, Fernbrook Assisted Living, and Summer House Memory Care and inspected annually. LPA observed fire extinguishers in Los Padres, Santa Ynez, and the Administration Building were charged but last serviced on multiple dates in 2020 and 2021 including 10/29/2020 and 03/18/2021. No other deficiencies were observed during the visit, all infection control protocols are implemented and being followed. Exit interview completed, deficiencies cited on 9099-D, copy of report and appeal rights emailed to Administrator/Licensee.