Routine inspection·August 3, 2022

Licensing Program Analysts (LPAs) Kelly Dulek and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 09:55AM. This annual had a specific emphasis on infection control practices and procedures. The LPAs met with Licensees Teresita and Larry Wayne and discussed the reason for the visit. The LPAs, along with facility Licensee Larry Wayne, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPAs observed the required postings in the common area. Two (2) fire extinguishers were observed to be fully charged and purchased on 02/27/2022. Smoke detectors were tested at 3:03PM and were functional at the time of the visit. Carbon monoxide detector was tested at 3:04PM and was functional at the time of the visit. The backyard has a covered outdoor area equipped with furniture for resident use. LPAs observed the exterior of the facility to contain items on the side of the house and in the backyard. The licensee stated these items are going to be moved to a new shed or donated. There were no bodies of water noted. The garage was observed locked. At 10:02AM, LPAs observed a knife in the backyard area on top of a chair. At 10:05AM, LPAs observed a second knife on the outdoor patio on top of a ledge/shelf. The laundry room was observed to be locked and contained items the Licensee stated will be donated. Licensee stated one of the laundry machines is currently inoperable and laundry is being taken off site to wash. Report Continued on LIC 809-C KITCHEN : Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All cleaning supplies were observed to be locked and properly stored at the time of the visit. At 10:20AM, LPA observed the water temperature at 114.1 degrees Fahrenheit. BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 (four) total bedrooms; 2 (two) are currently occupied for resident use, 1 (one) is locked and being used for storage, and 1 (one) was observed locked and designated as a staff room. RESTROOMS: The LPAs noted there are 2 restrooms in the facility; one is designated for resident use and one is for staff use. LPAs observed the resident restroom. Resident restroom was clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 10:16AM, LPAs observed accessible personal grooming and hygiene items, including shampoo, Aquanet hairspray, ointment, DermaDaily lotion, and toothpaste, on the bathroom counter, accessible to residents in care. At 10:22AM, LPAs observed the water temperature in the resident restroom to be 114.4 degrees Fahrenheit. RESIDENT FILES: Were reviewed at 10:55AM. At 11:06AM, LPAs observed Resident #1 (R1) has a diagnosis of dementia and has a physician's report dated 09/11/2019; physician's report indicates R1 is "at risk if allowed access to personal grooming and hygiene items." R1's appraisal is dated 10/05/2019. During file review, Resident #2 (R2)'s file was reviewed and did not contain a medical assessment. INFECTION CONTROL: During today’s visit, the LPAs spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPAs observed all visitors to be wearing masks, however staff and residents are not consistently encouraged to wear face coverings in common areas. The LPAs observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Licensee stated that neither of the 2 regular staff are vaccinated, neither has an exemption on file and both staff are not COVID tested weekly. To date, the facility has not submitted an Infection Control plan. Report Continued on LIC 809-C The following recommendations were made: - N95 fit testing for all staff - Post PINs and educate staff, residents, and families on changing policies and procedures from the Department -Staff and residents should be encouraged to wear masks while in common areas -Facility should have a backup plan for staffing The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email.