Routine inspection·January 10, 2022

Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 10:00am. This annual had a specific emphasis on infection control practices and procedures. When the LPA arrived, there was two staff and six residents present. The LPA met with Administrator Cilva Toume and explained the reason for the visit. The LPAs 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. KITCHEN: Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPAs observed the single-occupancy resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. 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 LPA observed all the required postings in the foyer, bathroom and the common spaces. The backyard has a covered outdoor area with furniture for resident use. There is an in-ground pool; at 10:20 a.m., whereas the lock was engaged, the LPA was able to open the gate without issue. The LPA observed that the self-latch was rusted. Once observed, the Administrator ensured that the gate was locked within five minutes of observing the unlocked gate. The LPA observed that the gate was locked at 11:28 a.m. The LPA explained the reason as to why a citation was being issued for a zero-tolerance violation. The Administrator believed that the citation should have been waived, as the gate was secured within five minutes. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The Administrator asked for additional PPE supplies. 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. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate. Observed deficiencies noted on LIC 809D. Exit interview conducted, and a copy of this report issued. Civll penalties assessed. Appeal rights discussed.