Routine inspection·August 19, 2022

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an Annual Required 1 Year inspection and met with facility care staff, Maybelle Conge. Office manager, Theresa ilagan "TJ" arrived a few minutes later and Administrator, Rashmika Mahawar was not present during inspection. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA observed residents were engaged in activities posters outside notifying visitors that mask must be worn in the facility. Once inside, LPA was screened by a caregiver. LPA confirmed that facility is conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature. Hand sanitizer is located tin the front area only as residents lack hazard awareness. LPA observed staff had masks on during this visit. Commonly touched surfaces are disinfected daily and after use. Facility documents and continues to screen residents daily and staff when they come on shift. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to be trained on infection control and Personal Protective Equipment, but have not been N95 fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced February 2022. Continued on LIC809C Continued from LIC809C Office Manager and LPA discussed their Emergency Disaster Plan. Facility has submitted their Infection Control Plan. LPA consulted regarding required poster PUB475 that needs to be enlarged and placed in area visible to all residents and visitors. Poster was observed behind other posters in front office space. LPA consulted regarding how to maintain records. Facility has two wings and is licensed for 30 residents and during todays visit the push buttons to call staff were not functional. LPA will review documents and fire clearance for side internal doors and exterior door protocol and fire department approval, along with front door delay egress that is used by push button, rather than push door. LPA tested front door and door is able to be opened after a small button located on right side of door is pushed - LPA advised staff not to cover button and button must be visible to ALL. Licensee/Administrator to submit updates of the following documents by 09/19/2022: LIC 308 Designation of Responsibility. LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of current Administrator's Certificate Copy of current Lease/Rental Agreement Copy of Liability Insurance See report LIC809-D for Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights were provided. A civil penalty was applied for $500.00 for fire safety, Zero Tolerance.