Routine inspection·May 9, 2022

Licensing Program Analysts (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by staff Elia Cuevas. Licensee Kelly Eriksen arrived during the visit. There were 6 residents present at the facility, 2 on hospice. LPA arrived at the facility and had temperature checked. All staff temperatures checked and logged each shift. LPA toured the facility with staff Elia Cuevas. During tour on 5/9/2022 facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 4/27/2022 at the time of the visit. A sample of 1 out of 1 Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility staff understands that food stored in the kitchen refrigerator must be properly stored as per regulations. Hot water temperature measured 113.7 degrees F and 117 degrees F within acceptable regulations of 105 to 120 degrees F in 2 of 2 resident’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Infection Control: Facility has submitted a mitigation program plan that was approved on 6/27/2021. Posters have been placed at facility. Facility has PPE supply stored in Hallway closet. Residents’ medications are centrally stored and locked in the office file cabinet. Facility has a 30-day supply of medication for residents. Residents do not wear masks inside the facility. Facility offers activities of Tai Chi, Indoor gardening, walks, and bingo for the residents. In addition, facility has a designated area for visitors in the backyard, living room, and/or in the bedrooms when possible. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and all have been N-95 fit tested. Continue LIC 809-C LPA reviewed Licensing Information System (LIS) with licensee who stated that is corrected and updated at this time. In addition, LPA advised facility to contact County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA was presented with proof of CPR & 1 st Aid certification for staff which files were reviewed. Administrator Certificate’s for Kisa Doss # 6022355740 Exp. 3/7/2023 & Kelly Eriksen #6027539740 Exp. 11/4/2023 All staff have received COVID booster vaccinations and exclusively work at this facility. There were no deficiencies cited at this time. LPA Hansen is requesting Licensee to update and submit the following documents by 5/27/2022 to SRRO: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 610E-S Supplemental Emergency Disaster Plan for RCFE LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Proof of Liability Insurance