Facility Evaluation Report

On 5/13/22 at 1:50 PM, Licensing Program Analysts (LPAs) K. Nguyen and L. Francisco arrived unannounced to conduct Infection Control Inspection. LPAs met with Direct Support Professional (DSP), Sabrina Balal and explained the purpose of the visit. Administrator was not available during the visit. Administrator gave verbal permission for LPAs to deliver the report to DSP Sabrina.

During the Infection Control Inspection, LPAs toured facility with DSP including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:

· At 2:10 PM, LPAs observed the padlock attached on the centrally stored medication cabinet was not properly locked. Deficiency cleared during visit. LPAs observed staff locked the centrally stored medication.

· At 2:40 PM during record review, LPAs were unable to review staff 1 (S1)’s file because staff did not have access to the server (Paylocity) which is used to maintain staff records.