Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection – 1 yr. Infection Control inspection met with staff, Dongmei Graves. LPA conducted a Risk Assessment call with Licensee prior to the visit and was informed that he was not able to come to the facility due to personal issues. However, Licensee gave authorization to staff to sign the report.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that staff were wearing masks during this visit. At approximately 1:20pm LPA observed and verified that staff (S1 and S2) that were present and providing care at the facility were not associated to the facility Personal Report/Roster in Guardian. Licensee stated that S1 and S2 worked at his other facility. LPA confirmed that S1 and S2 were associated to other facility. Licensee agreed to contact CCL office to associate both staff to this facility. ***Civil penalties are being assessed in the amount of $250 for repeated violation of allowing a person to work, reside or volunteer in the facility without a fingerprint clearance or exemption.

LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms. Hand sanitizer are located through the facility. Facility has a bathroom that is kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least once a day. Facility has designated an outdoor area for visitation. Facility staff have been trained on PPE protocols, but have not yet been N-95 fit tested. Staff and residents are being monitored daily and facility does document daily screening results in a binder. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate of staff and residents. Day program staff come to the facility to take them out for activities once a week on average. Facility has games and other activities for client use during off days. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, gowns and hand sanitizer. Facility has submitted their Covid Mitigation Plan and was approved on 3/12/21. 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.