complaint·August 19, 2022

Continued from LIC9099 When LPA arrived at the facility, three staff did not have masks on; one in the reception area and two in the dining room, one of which was less than six feet from an unmasked resident. Facility's Covid Mitigation Plan says, in part, the following: (Pg 7) Facilities with Covid - "If an active case of COVID-19 is identified in the community (staff or resident), all staff and residenst are tested every 7 days, or as directed by the county health department"; (Pg 13) "All facility staff are wearing a face covering while on the premises"; (Pg 15) "Our Executive Director/Administrator takes primary responsibility for communicating with all relevant parties regarding COVID-19. Communication is done via phone calls, email, written letters, and updates to our website." Evidence shows that multiple areas of the Covid Mitigation Plan are not being followed. Facility is not safe, sanitary and in good repair - Complaint alleges that the delayed egress door into Memory Care is not working. Also, that the live-in staff do not pick up their dog's feces and that there are urine stains on the carpet. During inspection LPA conducted a walk through and observed the following: LPA did not see feces or stains that were necessarily urine. The facility did not smell like feces or urine. LPA did confirm through observation that the delayed egress door into Memory Care is not working. It is not locking and the alarm does not sound. Administrator did show LPA that the notification to staff's phone showing the door was open does work so staff are notified in that way. LPA walked into the Memory Care outdoor area and observed that there are three gates that leave this area. One is locked and two opened but did not sound an alarm. The delayed egress door that goes into this area from the Memory Care living room is not locked or alarmed and once someone goes through it into the outdoor area, the door locks behind them and someone from inside the building must let them in. This does not allow for residents to wander freely inside and outside, which is a requirement of regulation. Inside the facility, LPA observed two discolored areas on the ceiling near the Assisted Living common area. Staff explained that the spots were due to plumbing in the ceiling that was leaking. One spot was brown and black and approximately 10 inches long. The carpet below the spot was not discolored or wet and it did not appear that water was leaking onto the carpet. The allegations that Facility did not follow their Covid Mitigation Plan and Facility is not safe, sanitary and in good repair is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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.