Routine inspection·March 25, 2022

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Staff Rhandy Abad at 9:30 a.m. and explained the reason for the visit. Administrator Charrisse Bradley arrived a short time there after. The LPA toured the physical plant areas inside and outside with Rhandy Abad at 9:45 a.m., to ensure there are no health and safety hazards. BEDROOMS: The LPA observed five (5) resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. A staff bed was observed in the dining room area that has now been converted to an office/staff room. The facility sketch reflects the staff room as bedroom #1 which is now a resident room. The administrator was advised to notify the department when making any changes to the facility sketch and provide a new plan of operation and new facility sketch with the changes. RESTROOMS : Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Restroom hot water measured 110.5 Fahrenheit at 10:30 a.m. Continued on LIC 809-C KITCHEN/FOOD SERVICE AREA: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 9:50 a.m. the LPA observed an unlocked kitchen drawer containing kitchen knives and sharps. Hot water measured 111.5 Fahrenheit at 9:53 a.m. At 10:07 a.m. expired cooking spices were observed on the kitchen counter. At 10:11 a.m. expired canned goods were observed in the dining room pantry, refried beans, sauerkraut, staff disposed of the expired items. The Administrator was advised that a full audit of canned goods and spices needed to be conducted and all expired items are to be thrown out. COMMON SPACES/GARAGE: 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 required postings in the hallway. However, did not observe the required provider information notices (PIN) posted upon entry regarding visitation. The LPA observed a screened fireplace in the living room. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. The smoke detectors and carbon monoxide detector were tested between 10:24 a.m. - 10:25 a.m. and were operational. The fire extinguisher was observed to be full and last bought on 1/2022. At 9:54 a.m., the laundry area/garage was unlocked, and there were accessible laundry supplies and chemicals. A refrigerator inside the garage contained a unlocked medications and a cabinet with accessible over the counter medications was also observed. Staff secured garage at the time of observation. The garage contains additional perishable food items. BACKYARD : The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Continued on LIC 809-C INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. However, staff were not adhering to sign in policy. The LPA reminded the Administrator that sign in policy is still in effect. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed from the Regional Office upon request. Upon arrival the LPA observed staff not wearing face masks. Staff were reminded that face masks are required at all times and complied at the time of observation. The Administrator was reminded that masking is still required by all staff live in or not and to ensure that all staff are reminded of this policy. 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 does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control. 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.