Post-licensing visit·March 18, 2022

Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct a Post Licensing inspection and met with caregiver, Cheryl Alcones. Licensee, Arthur Alcones was available by phone and gave permission for caregiver to sign report. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival, caregiver took LPA's temperature and asking standard Covid screening questions. LPA noted that the temperature on the thermometer was very low compared to LPA's normal temperature. Review of visitor log revealed that all visitors appeared to have low temperatures. LPA suggested to caregiver that the battery may need to be changed or the thermometer may need to be replaced. Per conversation with caregiver, they verbally confirm with visitors that they are vaccinated but have not requested the actual vaccination card. LPA instructed caregiver that visitors must provide proof of vaccination per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility and observed the following: Facility has some COVID-19 posters in the hallway and hand washing signs in bathrooms but there are no postings on the front door or in the entryway. LPA suggests adding posters to more central areas of the facility Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had a mask on during this visit. Commonly touched surfaces are disinfected once per day . Facility maintains documentation of resident daily temperatures but per caregiver, they take staff's temperatures at the beginning of their shift but it is not being documented. LPA instructed staff to start documenting staff temperatures as well. Facility has a designated visitation area outside and is allowing for visitation in resident rooms. Staff have completed PPE training and have been N95 fit tested. Continued on LIC809C Continued from LIC809C Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including masks, gloves, face shields and hand sanitizer. Additional PPE should be stored at the facility. Facility maintains a 30 day supply of medication. Licensee has put in a fence to enclose the entire yard to decrease the risk to a resident who may have wandering behavior. Licensee will submit an update to their Dementia Care Plan. Licensee and LPA discussed their Emergency Disaster Plan. No deficiencies cited during this inspection.