Facility Evaluation Report

Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with staff, Teresita Sta Maria. LPA called and spoke with Aidan Castrence, administrator, who arrived after several minutes. LPA informed the purpose of visit..

The facility consists of six buildings (building #'s 2, 3, 4, 5, recreation building and office). Facility has a completed COVID-19 mitigation plan that was approved on May 2021.

LPA started the inspection with Teresita Sta Maria and continued with Aidan Castrence. LPA observed screening station located by the entrance door inside the recreation building with visitor's log, hand sanitizer and no touch temperature probe and disposable gloves. Routine symptom screening (+/-) temperature and symptom checks are done for all staff, clients and visitors. Clients are screened for COVID-19 symptoms and temperature checked daily. Infection control designated leader is the administrator.

Adequate supply of centrally stored PPEs was observed. There were at least 7 days of nonperishable and 2 days of perishable foods. Fire extinguisher in each building were observed fully charge; however, tags showed serviced May 15, 2020. Hot water temperature in the bathroom in building #2 was tested and measured at 108.20 degrees Fahrenheit.

1. No sneeze and cough etiquette poster in recreation building.

2. No "Welcome Visitors" poster on facility entrance.

3. Trash can without lid in building # 4's bathroom and trash can's lid in the kitchen is not "touch free".