Routine inspection·August 17, 2022

Licensing Program Analyst (LPA) Alviso, arrived unannounced to conduct an Required-1 Year inspection and met with Sandra Ambrecht, lead caregiver/back-up to the Administrator. This inspection is focused on the Infection Control procedures and practices of the facility. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. The new updated Infection Control Plan was recently submitted as required by the Department. Fire clearance is approved for six (6) non-ambulatory. There were six (6) residents in care at the facility during the inspection. Residents are screened daily, and observed for any changes, all information is logged. Facility was found to be at a comfortable temperature for the residents in care. LPA observed all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) for use by staff and others, residents and/or visitors as needed or wanted. Staff Sam was observed wearing a mask, as required, upon LPA's entry into the facility. LPA observed the following during the inspection: Staff didn't screen the LPA upon entry and/or at any time ask to screen the LPA. The LPA discussed the screening requirements with staff Sam. This deficiency will be cited, Administrator Qualifications and Duties 87405(d)(2)-see LIC809D. Continued on page LIC809C.. LPA observed a large pair of scissors in a resident's room (R1), and observed three pairs of small scissors and a metal sharp pointed mail opener in another resident's room (R2); These items pose a danger and risk for residents in care, this deficiency will be cited, Care Of Persons With Dementia 87705(f)(1). LPA observed a residents room to smell strongly of urine: LPA observed that the residents bathroom also smelled strongly of urine. The LPA observed that the rug in front of the residents bed showed that there were many stains; Staff stated to the LPA they didn't notice the stains. LPA asked if the rug in the residents room is cleaned on a regular basis, and the incontinent resident's bed wiped down as needed as staff stated to the LPA that the resident was changed and is clean and dry. The staff stated to the LPA the rug was cleaned a about a month ago, and the resident's bedding is washed as needed. LPA stated that part of caring for incontinent residents is to also ensure that the facility remains free of urine odors. Deficiency cited, 87625(b)(3) Managed Incontinence. LPA observed two(2) facility fans that had very dirty fan blades with lots of dust accumalated-both fans were running. LPA obtained pictures. The staff turned both the fans off and acknowledged to the LPA that the fans were dirty and needed to be cleaned. This deficiency will be cited, Maintenance and Operation 87303(a). All deficiencies cited are found on LIC809D pages. Licensee to submit by 8/31/22 the following updated forms: LIC308 - Designation of Administrator Responsibility LIC500 - Updated Personnel Report LIC610 - Updated Emergency Disaster Plan, Copy of Current Lease Agreement(if home leased to the Licensee) Copy of Current Liability Insurance Copy of current Administrator Certificate Copy of updated Disaster/Emergency Evacuation plan. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 and/or Health & Safety Code Deficiencies not corrected within specified time frame and/or repeat violations within 12 months, may result in civil penalties being assessed. Exit interview conducted with staff Sam Ambrecht. Appeal rights provided for the Administrator.