Facility Evaluation Report

On 02/29/24 at 1:20PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (S2) and spoke with administrator (ADM) on the phone who authorized S2 to act on her behalf and sign the reports. LPA explained the purpose of the visit with S2 and ADM. LPA observed ADM has a current administrator certificate# 6056379735 which expires 09/26/2024.

At 1:50PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, clients and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 70 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 2 staff and 4 resident files. LPA also conducted 2 staff and 2 resident interviews during visit.

Updated copies of the following documents were collected for facility file:

 LIC308- Designation of Facility Responsibility

 LIC610E- Emergency/Disaster Plan including infection control plans

No deficiency observed during visit. Exit interview conducted and a copy of this report provided .