Letis at Valencia Mdsl 1

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed a disaster plan review conducted November 2022. However, documentation of a more recent disaster plan review conducted was not available for review. 2. In an interview, E1 acknowledged the disaster plan required in subsection (A)(1) was not reviewed at least once every 12 months.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Staffing Policy." The policy stated "Staff at this facility are working on 12-hour shifts everyday. The first shift is from 6:00 AM to 6:00 PM on the same day, and the second shift is from 6:00 PM to 6:00 AM the following day." 2. A review of facility documentation revealed disaster drills for the following dates and shifts: -May 2022, First shift; -August 2022, 12:30-12:55 (No AM or PM marked); -November 2022, 11:00-11:30 (No AM or PM marked); -February 2023, First Shift; -May 2023, First Shift; and -August 2023, First Shift. However, documentation of an employee disaster drill was conducted on each shift at least once every three months was not available for review. 3. In an interview, E1 acknowledged an employee disaster drill was not conducted on each shift at least once every three months and documented. This is a repeat citation from the previous compliance inspection conducted on October 20, 2022.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months, which posed a health and safety risk to residents and employees if the employees were unable to implement the evacuation plan. The deficient practice posed a risk if employees were unable to safely evacuate residents in an emergency. Findings include: 1. A review of facility documentation revealed evacuation drills done on the following months: -May 2022; -November 2022; and -May 2023. However, documentation of an evacuation drill for November 2023 was not available for review. 2. In an interview, E1 reported forgetting to conduct the drill due to other events occuring during the time the evacuation drill was due. E1 acknowledged an evacuation drill for employees and residents was not conducted at least once every six months, which posed a health and safety risk to residents and employees if the employees were unable to implement the evacuation plan.

Based on observation and interview, the manager failed to ensure an evacuation path was conspicuously posted in each hallway of the assisted living facility. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed an evacuation path was not cospicuously posted in each hallway of the assisted living facility. 2. In an interview, E1 acknowledged an evacuation path was not conspicuously posted in each hallway of the assisted living facility.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a spray can of "Lysol" disinfectant spray in an unlocked cabinet in the kitchen. 2. In an interview, E1 acknowledged toxic materials stored by the facility were not stored in a locked area and inaccessible to residents.