Routine inspection·July 15, 2022

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Leonardo Dela Cruz and Administrator, Glenn Vargas. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, LPA observed posters outside notifying visitors that mask must be worn in the facility and visitation policy. Once inside, LPA observed a screening station near the entrance and LPA was asked to sign in. LPA confirmed that facility is conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected three times per day and after use. Facility maintains documentation of staff and resident daily temperatures. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff have completed PPE training and have been N95 fit tested. LPA and Licensee discussed visitation and activities. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced August 2021 and facility will have them serviced next month. Hardwired combination smoke and carbon monoxide detectors were tested and operational. Continued on LIC809C Continued from LIC809 Licensee and LPA discussed their Emergency Disaster Plan and Infection Control Plan. Facility will be sending the Infection Control Plan to CCL once completed. Licensee/Administrator to submit updates of the following documents by 8/15/2022: LIC 308 Designated Administrator LIC 500 Personnel Summary LIC 400 Affidavit Regarding Resident Cash Resources (if changes) LIC 402 Surety Bond LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility Client’s/Resident’s No deficiencies cited during this inspection.