Routine inspection·May 13, 2022

Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required-1 Year inspection at approximately 1:00 PM, and was initially greeted by staff. Licensee/Administrator, Angelica Martinez arrived shortly The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry LPA was asked fill out a screening form and sign in. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per staff, updated infection control guidelines and PINs are communicated to responsible parties verbally. Staff completed Personal Protective Equipment (PPE) and infection control training last year through Kaiser. High touch surface areas are disinfected daily. Due to residents having private rooms they could isolate in their own rooms if they became ill. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation. Licensee plans to fit test staff after undergoing training. Residents' emergency contact information has been updated and staff indicated they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked hallway closet and in locked cabinets under the kitchen and bathroom sinks. A 30 day supply of medications are locked in administrator's office. The facility has a sufficient supply of PPE located in garage. All exit alarms on exit doors were working properly. Facility is not currently conducting surveillance testing. All staff have received their booster shot and all residents have received their booster shot. Continued on LIC 809C During tour of the facility LPA observed two half rails placed together that ran the full length of a resident's bed. Interview with administrator revealed resident is not receiving hospice services. Administrator provided discharge paperwork indicating the need for bed rails. Paperwork does not specify half or full bed rails. LPA requested the following updated documents: LIC 500 LIC 9020 Emergency Disaster Plan Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties Exit interview conducted with administrator and a copy of this report printed for the facility.