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13 | On January 12, 2022 at XXam, Licensing Program Analyst (LPA) DeAnna Williams-Lyons and Licensing Program Manager (LPM) Laura Munoz made an announced visit to this facility to conduct a complaint investigation. LPA and LPM met with Paul Kelly and stated the purpose of today’s visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a mask was worn for the following Personal Protective Equipment (PPE).
The Department received information that the licensee posted holiday photos during December 2021 that pictured staff unmasked working around clients. The Department conducted an internal search and observed the facility facebook page uploaded holiday photos on December 25, 2021 with staff taking photos with visitors, each other and clients without wearing required face coverings. Pursuant to California Department of Public (CDPH) Health Order dated January 5, 2022, health order requires masks to be worn in all indoor public settings, irrespective of vaccine status until February 15, 2022. The statewide mask mandate order was in effect effective December 15, 2021. CONTINUED ON LIC9099C |
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32 | In addition, California Department of Social Services (CDSS), Provider Information Notice (PIN) 21-33-ASC dated July 27, 2021, requires all CDSS licensed day programs to follow State Public Health Order of July 26, 2021 requires that all licensed day programs must strictly adhere to CDPH masking guidelines. PIN 21-33-ASC further states that facility staff are required to wear FDA-cleared surgical masks in indoor settings anywhere they are working with another person. A review of the facilities Department approved Mitigation Plan indicated on page 13 of 28 that all facilities staff are wearing face coverings while on the premise.
Facility staff failed to protect the personal rights of clients in care to receive safe and healthful accommodations, in that facility staff failed to wear face coverings while working with clients in care violating an official government order requiring the wearing of face coverings while working under specified conditions. In addition, the licensee failed to follow approved Mitigation Plan Report engaging in conduct inimical to the health, welfare, and safety of clients in care.
Based LPA’s investigation observations, interviews conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of regulations, Title 22 are being cited on the attached LIC9099D.
During today’s visit, LPA and LPM provided the licensee with the following documents:
• PIN 21-53-ASC – Adult and Senior Care Facility Worker Corona virus Disease 2019 (COVID-19) Vaccination and Booster Requirements
• PIN 21-33-ASC – Adult Day Program Infection Control Guidance
• California Department of Public Health Order Subject: Guidance for the Use of Face Masks |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/13/2022
Section Cited
CCR
82072(a)(2) | 1
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7 | 82072 Personal Rights
(a) Each client shall have personal rights which include, but are not limited to, the following:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. | 1
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7 | The licensee shall conduct an in-service with all staff to review and adhere to all required Public Health Orders. A date of the training and proof of attendance and completion shall be submitted by 1/19/2022 |
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14 | This requirement is not met as evidenced by: Based LPA’s investigation observations, interviews conducted and record(s) reviewed, facility staff failed to protect the personal rights of clients in care in that facility staff failed to wear face coverings while working with clients which poses an potential health and safety risk to residents in care. | 8
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Type B
01/21/2022
Section Cited
CCR
82061(a)(1)(F) | 1
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7 | 82061 Reporting Requirements
(a) Upon the occurrence, during the hours the day program is providing services to the client, of any of the events specified in Section 82061(a)(1), a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in Section 82061(a)(2) shall be submitted to the licensing agency within seven days following the occurrence of the event. Events reported shall include, but not be limited to, the following:
(F) Epidemic outbreaks | 1
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7 | The licensee shall conduct an in-service with all staff to review and understanding of the approved Mitigation Plan. A date of the training and proof of attendance and completion shall be submitted by 1/19/2022 |
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14 | This requirement is not met as evidenced by: Based LPA’s investigation observations, interviews conducted and record(s) reviewed, facility staff failed to follow approved Mitigation Plan which poses an potential health and safety risk to residents in care.
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