Facility Evaluation Report

Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with staff, Theresa McIntosh Ademi and Leesa Durst -Weisman. LPA spoke with CRT Manager Nathalie Lee who authorized Durst-Weisman to be with LPA during inspection. Benjamin Blake, administrator, arrived after about an hour.

Facility has an approved LIC808 COVID-19 Mitigation Plan.

LPA toured the facility with Durst-Weisman. LPA inspected the activity and tv rooms, kitchen, dining area, bathrooms/toilet on the first and second floors. LPA randomly selected bedrooms on the first and second floor for inspection. LPA observed screening station by the front entrance with visitor's log, hand sanitizer, and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and residents. Centrally stored PPEs inspected. Fire extinguishers were observed fully charge and tags showed serviced January 21, 2022.

1. Cleaning supplies in unlocked cabinet under the kitchen sink.

2. Broken toilet paper holder in the second floor bathroom.

4. No handwashing posters in the kitchen and toilets.

6. PPEs not sufficient for 30 days for 5 staff.

7. No paper towel in the bathrooms/toilets.

LPA verified that staff were not fit tested for N95 respirator.