A Home at Shaw

Type of visit: Required - 1 Year

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 07/21/2022 at 01:11pm. LPA encountered administrator Serapia Beltran (Admin) outside the front door. Admin was leaving the facility to meet with a family, and gave caregiver Floro Taon (CG) permission to conduct the inspection on her behalf. LPA toured the facility, including front hallway, kitchen, living room, all bedrooms, all bathrooms, dining room, back yard and laundry room. Upon entrance to facility, LPA was screened for symptoms and temperature was taken. All staff observed to be wearing masks. Admin confirmed that all staff and all but one residents have been vaccinated. Facility noted to have a 30 day supply of masks, N95s gloves, face shields, and gowns. No prohibited items noted in resident rooms. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to have been inspected in June of 2022. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Smoke/carbon monoxide detectors were tested and observed to be operational. Hand washing signs were observed in the facility bathrooms. Water temperature observed to be 115.3 *F in facility bathroom. Facility temperature observed to be 71*F. Social distancing signs observed to be posted in all public areas. No deficiencies cited during today's visit. This report was reviewed with facility caregiver Floro Taon, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 21, 2022

Type of visit: Case Management - COVID-19

Licensing Program Analyst (LPA) Joanne Roadilla conducted a Technical Assistance (TA) tele-visit today via Teams Meeting with Program Clinical Consultant (PCC) Nurse Helen Shi, RN and Licensing Program Manager (LPM) Jackie Jin. The purpose of the visit was to provide guidelines for Infection Prevention and Control. Present during the tele-visit were licensee Pia Beltran, administrator (ADM) Gladys Smart and staff Floro Taon (S1). The facility was toured virtually, and the following areas were inspected: central entry, living room, dining room, kitchen, bathrooms, and residents' bedrooms. Based on facility tour and interview with ADM and S1, the following recommendations were provided today: 1. Keep thermometer by the screening station. 2. Keep the isolation rooms closed. 3. Covered trash bin for PPE disposal should not be inside the bathroom. The donning station should be separate from the doffing station. 4. Keep supplies for disinfecting near the isolation rooms. 5. Load laundry separately between clients and disinfect the area after each load. No deficiencies issued per Title 22 of the California Code of Regulations. LPA reviewed report with, and a copy provided to Gladys Smart for signature.the state’s words, verbatim · CDSS document, Sep 2, 2021

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management tele-visit at the facility today. The facility is licensed to serve 6 residents 60 years and over, 5 may be non-ambulatory and 1 may be bedridden. The facility has been granted a hospice waiver for four (4). LPA met with Administrator (ADM) Gladys Smart and discussed the purpose of the visit. On 08/19/21, ADM submitted a request for an exception to retain a resident (R1) who has been diagnosed as bedridden and dependent on others for all activities of daily living (ADLs). At 5:35pm, LPA conducted a virtual tour of R1’s shared bedroom via FaceTime with ADM and a facility staff. LPA observed that R1 is not able to reposition and is bedridden. LPA also observed that R1 is not capable of grooming oneself. ADM and staff stated R1 is not able to perform any other ADLs without caregiver assistance. LPA reviewed R1's files including physician's reports (LIC602A), appraisal/needs and services plan (LIC625) and functional capability assessment (LIC9172) and discussed with ADM during the visit. No deficiency cited during today's tele-visit. LPA provided a Technical Assistance during today's tele-visit, see LIC9102. A copy of the report was discussed with and provided to Gladys Smart via e-mail for review and signature.the state’s words, verbatim · CDSS document, Aug 24, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Karen Taku conducted an unannounced annual (Infectious Control) Inspection today. LPA met with Administrator (ADM) Gladys Smart. At 10:10am, LPA entered the facility through the designated entry point and was screened by staff. All staff were observed wearing face coverings. At 10:25am, LPA was accompanied by the ADM during a tour of the facility, inside and out. LPA observed hand sanitizer readily available in all resident bedrooms. All three restrooms were observed with hand washing posters, liquid soap, paper towels, and a touchless trash can. COVID-19 prevention posters were observed in the main dining/living room area. LPA observed an adequate supply of PPE readily available to staff. Backyard/patio area observed in good repair. Per Administrator, routine symptom screening is conducted twice a day. The facility is currently accepting visitors inside and in the backyard patio area of the facility. All visitors are required to wear mask when visiting inside the facility. LPA obtained copies of the following documents during visit: 1. LIC 500- Personnel Summary 2. LIC 308- Designation of Administrative Responsibility 3. LIC 610- Emergency Disaster Plan 4. Current Administrator's Certificate The facility is adhering to the COVID-19 Mitigation Plan approved on 3/18/21. No deficiencies were cited. Exit interview conducted with the ADM and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 21, 2021