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25 | On 11-18-22 at 10:45am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a health and safety check. LPA met with Administrator Melissa Orello and explained the purpose of the visit. LPA conducted facility tour including common areas, resident rooms, dining area, kitchen area, and outside area to ensure compliance with Title 22 regulation. LPA also interviewed Administrator and staff1 (S1). Upon entry LPA was not screened immediately for COVID symptoms. LPA observed facility during tour to be sanitary with no foul odors detected. Carpets and walls were clean. Resident rooms had appropriate furniture and furnishing. Facility has adequate food supply on hand.
Water temperature was tested in assisted living and memory care side in various hallways with temperature ranging between 105*F and 120*F. LPA reviewed facility file documentation including maintenance log and recent replacement of water heater. Maintenance records indicate repair company was at facility on 11-14-22 to address a malfunctioning water heater which began on the weekend of 11-12-22 based on interviews conducted. Based on additional record reviews, facility did not notify licensing department within 24 hours of loss of hot water for a hallway section in assisted living.
Additionally, based on interviews, it was determined that administrator of record was not present in facility as of approximately middle October 2022 and new Administrator has been hired to act as interim Administrator of Record with no start date at this time. LPA also reviewed LIC 308 and LIC 500 and reviewed actual hours worked for designated substitute indicated on LIC 308. At this time, facility does not have an acting Administrator on duty 40 hours per week as required based on a department meeting held on 10/21/21. Additionally, based on today's visit and review of LIC 308 and LIC 500, facility did not have a designated substitute on duty.
Facility currently has 1 active COVID case on assisted living side who is currently isolated with precautions in place.. Licensing department did not receive report regarding COVID positive within 24 hours of occurrence. {Cont. on LIC 809C} |