Facility Evaluation Report

On 6/24/2022 at 12:25 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPA was greeted by Care Staff, Irene Joseph. Administrator, Meeran Saxena later arrived at 12:40 PM.

During the Infection Control Inspection, LPA toured facility with Administrator 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 Social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff.

During record review, LPA reviewed 3 staff records and 3 of 3 have health screening and TB test results on file. Facility has a mitigation plan on file.

THE FOLLOWING DEFICIENCY HAS BEEN OBSERVED

At 1:15 PM, during record review and interview, S1 has been employed since March 2022, and no vaccination exemption on file is maintained in accordance to Public Health Order and PIN 22-05.1-ASC

At 1:20 PM, during record review, weekly COVID-19 testing is not being conducted for S1 according to Public Health Order on September 28, 2021 and PIN 21-32.1-ASC