Routine inspection·June 29, 2021

Licensing Program Analysts (LPA), Farhaan Sarangi and Erik Gonzalez Campos arrived unannounced to conduct a Required 1 Year inspection at approximately 11:45 AM, and met with administrator Emmanuel Salas. The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry LPAs were screened for COVID symptoms and asked to sign in by administrator. At primary entrance LPAs observed temperature logs and visitor sign-in sheet. LPAs conducted walk through of the facility with administrator and observed COVID postings throughout. Mitigation plan was provided by administrator and approved on site by LPAs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. High touch surface areas are disinfected daily. An empty room is available as well as PPE to support a resident in isolation. Upon discussion with administrator it was noted that facility was no longer documenting daily temperature of residents or staff. Furthermore, it was noted that staff have not undergone Personal Protective Equipment (PPE) or infection control training. LPAs also observed S1 not wearing a mask. LPAs provided guidance to resume documenting symptoms and temperatures, contact local public health for training, and to ensure proper mask etiquette. Residents' emergency contact information has been updated and licensee confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked hallway closet. A 30 day supply of medications are stored in a locked cabinet, making them inaccessible to residents. The facility has a sufficient supply of PPE and hygiene supplies. All exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines. Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. Visits are occurring both inside the facility as well as on the outdoor patio area. In addition, during the Required 1 Year inspection, LPAs observed a full bed rail on one resident bed. Per Title 22- 87608(a)(5)(B)- Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. LPAs provided technical assistance (See LIC 9102). LPAs requested following documents: LIC 309 LIC 400 LIC 308 LIC 500 LIC 402 Emergency Disaster Plan LPAs unable to print, will email report and supporting documentation to administrator. No deficiencies cited during this inspection