Routine inspection·August 4, 2022

Licensing Program Analysts (LPAs) Jeannette Olson and Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 12:00 pm and was greeted by Staff 1 (S1). Administrator Peter Bonilla and Interim-Administrator Mark Cortes were present at the time of arrival. There were 59 residents in care in the Assisted Living unit with 1 medication technician and 3 caregivers on duty. In the “Compass Rose” Memory Care unit, there were 21 residents with 1 medication technician, two caregivers, and 1 activities coordinator on duty. The Compass Rose Resident Services Director who currently oversees the Assisted Living and Memory Care units of the facility was also on duty. A Mitigation Plan has been submitted to CCLD. LPAs explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. There are 18 residents currently on hospice. Entrance interview conducted: The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked. The facility was seen to be in good repair inside and outside. Throughout the facility, there are approximately 10 fire extinguishers and 5 fire pull alarms. The pull fire alarms alert the local fire department when activated. Fire inspection was most recently conducted on 6/17/2022 and 6/21/2022. There are approximately 81 dual carbon monoxide detectors and smoke alarms throughout the facility. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. LPA observed the dining areas are clean. LPA observed kitchen cabinets, refrigerator, stove, and counters are clean. Medications and First Aid supplies/kits are kept in locked cabinets in the Assisted Living nurse’s station and in the Memory Care nurse’s station. Please continue to 809-C, Pg 2. 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. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of COVID-19. A single room can be dedicated with resident(s) who are suspected or tested positive with COVID-19. The facility has single rooms with restrooms and they are disinfected bi-weekly or daily in Memory Care. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located immediately outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room. The facility has proper cleaning and disinfectant sprays. 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. Staff who have a respiratory illness are requested to stay home and not report to work. 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 are well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked office. Facility observes 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 Certificate is valid. At approximately 3:01 pm, LPAs reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined there are 8 staff members currently working in the facility and have not been associated to the facility prior to their employment. Additionally, one staff member has not received a criminal background and/or fingerprint clearance and last worked in the facility on 8/4/2022. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D), Exit interview conducted. Report and Appeal Rights issued via email. Assisted Living Residents participate in activities such as special occasion celebration, music entertainment, Boce ball court, physical therapy, and excursions to local eateries and retail businesses. Memory Care residents participate in activities such as special occasion celebrations, music entertainment, and scenic drives. The facility has various sitting areas throughout the first and second floors including a library/reading area, faux fireplace, computer/business center for residents and staff, vending machines, beauty salon, physical therapy center, and a laundry room. The facility grounds are well maintained with walkways, sitting areas with covered tables and chairs, and raised garden areas. Throughout the interior area and outdoor area, the facility is conducive for socially distanced visitation. Chemicals and cleaning supplies are kept in two locked closets with no access to residents in care. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair. The facility has an entry point at the front door where residents, visitors, staff entering complete sign-in, symptom questionnaire and temperature screening. All documentation is kept in a file located at the front desk then later filed. The entry station has hand sanitizer along with a thermometer. All equipment and PPE supplies are kept in the Resident Services office and in a storage closet. Residents are screen 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 on the front door, entry area regarding COVID-19. Staff ensures that 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. The facility offers virtual and telephone communications to all residents in care. Residents, staff, and visitors are informed of the facility’s infection control policies. New residents and staff will be tested for COVID-19 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. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Administrator/Interim Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Please continue to 809-C, Pg 3.