Routine inspection·January 26, 2023

Licensing Program Analyst (LPA) Walters arrived unannounced to conduct an Annual Required inspection and met with Care Coordinator, Jennifer Ramos . The Administrator wasn't present for today's inspection, but was available by phone. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA was screened by receptionist for Covid-19 which included a temperature check and screening questions. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. Facility has additional disposable mask to provide visitors should they not have one. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters at the entrance and throughout the facility to promote hand washing and droplet precaution. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected at least twice per day. Continued on 809 C Facility continues to screen staff and residents and maintains documentation. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) and have been fit tested by local public health. Staff vaccine information is stored in each staff's folder. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Facility has submitted their Infection Control Plan and Mitigation Plan. LPA and JR also discussed a self-reported (SOC 341) Report of Suspected Dependent Adult/ Elder Abuse, that was reported to Community Care Licensing on 1/10/2023, The incident involved a non-staff member (NS1) who was observed being physically aggressive towards resident R1. LPA conducted interviews with staff who witnessed the incident and learned that on 01/10/2023, it was alleged that NS1 physically held down R1. Staff immediately intervened alerted management, who asked NS1 to leave the facility. Management alerted R1's responsible party, Ombudsman and Adult Protective Services. (APS). LPA received copies of NS1's file. No deficiencies cited during today's visit.