366412271-7-26-2021-18-AS-CCON-C5AQDC-20210726120432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366412271
Report Date: 07/26/2021
Date Signed: 07/26/2021 12:04:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	ERWIN LAKE ELDERLY CARE		FACILITY NUMBER:	366412271
ADMINISTRATOR:	YVONNE KURZEJA		FACILITY TYPE:	740
ADDRESS:	2052 STATE LANE		TELEPHONE:	(909) 585-4004
CITY:	BIG BEAR CITY	STATE: CA	ZIP CODE:	92314
CAPACITY:	6	CENSUS: 6	DATE:	07/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Marijane Tan - Caregiver		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to complete the facility's Annual Inspection. LPA Colvin met with caregiver Marijane Tan and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. The facility's Administrator was not available during today's inspection, but was contacted and spoke with LPA Colvin regarding the purpose of today's inspection. Below is a summary of what was observed: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with caregiver Marijane Tan, who LPA Colvin found to be successfully incorporating the several aspects of the facility's approved Mitigation Plan. Residents have hand sanitizer available to them in their rooms and bathrooms, and the bathrooms were stocked with hand soap and paper towels. LPA Colvin did not observe any hand washing guides in any of the bathrooms, and recommended for the facility to post them for residents to reference. LPA Colvin additionally observed the facility to have multiple postings throughout the facility for cough etiquette and social distancing. LPA Colvin requested to inspect the facility's Personal Protective Equipment (PPE) supply, which is stored on a bookcase in the living room. LPA Colvin observed the facility to have a 30-day supply of gloves, masks, and sanitizer, and isolation gowns. LPA Colvin went over the various recommended training for facility staff with caregiver Marijane in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Marijane informed LPA Colvin that at this time staff have not been fit tested, due to difficulties with getting an agency to come up the mountain to fit test for a small facility. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ERWIN LAKE ELDERLY CARE	FACILITY NUMBER: 366412271
	VISIT DATE: 07/26/2021

NARRATIVE

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Additionally, most residents have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA Colvin provided caregiver Marijane Tan with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

LPA Colvin inquired about if the facility is still conducting COVID-19 surveillance testing of their staff members. Caregiver Marijane Tan informed LPA Colvin that they have not been testing their staff members anymore, however, all staff and residents have been vaccinated. On 6/7/21, Community Care Licensing (CCL) issued a new Provider Information Notice (PIN) with updated guidelines on surveillance testing of staff members for COVID-19. PIN 21-28-ASC states that if at least 70% of all staff and residents in a facility have been fully vaccinated and do not have any symptoms of COVID-19, then the facility is not required to continue to conduct surveillance testing. Since over 70% of the facility is fully vaccinated, they are not required to continue to test their staff, unless they display symptoms or have close contact with someone who has tested positive for COVID-19. In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Caregiver Marijane Tan informed LPA Colvin that the staff continue to check resident's symptoms daily. LPA Colvin additionally confirmed that the facility is allowing for indoor visitation, and observed a sign-in sheet with proof of visitors being screened prior to entry into the facility.

During today's inspection, LPA Colvin observed two walkways/passageways which were blocked. LPA Colvin observed one of the two emergency exits (right) from the backyard to be blocked near the gate with a large black trash can, which was positioned in the walkway, making it difficult to pass by while remaining on the walkway. LPA Colvin additionally observed the sliding glass door in the dining room, which leads to the backyard, to additionally be blocked by two of the dining room chairs. LPA Colvin inquired as to why the chairs were in front of the door, and caregiver Marijane Tan stated that sometimes the residents like to sit there. Lastly, LPA Colvin observed two chairs on the deck in the backyard (directly across from the sliding glass door) to be in the middle of the walkway, instead of set back closer to the railing, which made the walkway difficult to use. The facility is licensed for six non-ambulatory residents, one if which can be bedridden. Due to the facility serving non-ambulatory residents, it is especially important for all walkways and passageways to be clear, so that they may walk with their assistive devices (wheelchair/walker) without issue. Deficiency cited

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ERWIN LAKE ELDERLY CARE	FACILITY NUMBER: 366412271
	VISIT DATE: 07/26/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	The facility was cited and an exit interview was conducted with caregiver Marijane Tan where a copy of this report, LIC 809D, appeal rights, and LIC9102 TA Advisory Notes was provided.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ERWIN LAKE ELDERLY CARE	FACILITY NUMBER: 366412271
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in at least three walkways/passageways (right backyard emergency exit, sliding glass door in dining room, and walkway outside across from sliding glass door) which poses a potential safety risk to persons in care.
	POC Due Date: 07/30/2021
	Plan of Correction
1 2 3 4	Licensee agrees to move objects blocking doorways/walkwaysto ensure residents may move about the facility without difficulty. Licensee to provide LPA Colvin with photographic evidence of cleared passageways/walkways mentioned to LPA Colvin by Plan of Correction date of 7/30/21.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

LIC809 (FAS) - (06/04)

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