Facility Evaluation Report

On 9/22/2022 starting at 10:15 a.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator and disclosed the purpose of the visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, and kitchen. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Mitigation Plan on file.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:

· At 10:20 a.m., LPA observed facility was not cleaned daily, many stains was observed on the toilet and table clothes.

· At 10:40 a.m., during record review, LPA observed Administrator did not keep clients' Centrally Medication Records on file.

· At 10:50 a.m., during record review, LPA observed facility does not have an Emergency Disaster Plan (LIC 610)

· At 11:00 a.m., during record review, Administrator admitted that no booster was received.

· At 11:10 a.m., during interview, LPA observed Administrator didn't have knowledge of keep update information from CCLD. Administrator admitted that she didn't have access to emails and she will designate her daughter to assist her.

· At 11:40 a.m., during interview, LPA observed Administrator didn't have active Administrator Certificate.