Facility Evaluation Report

On 8/30/2021 at 10:10 AM Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an infection control annual required inspection. LPA met with Maricris M. & Administrator Shugen Tio. Facility has census of 6. Facility is a level 4i.

LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. No bodies of water observed at the facility. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days.

Facility has enough 2-day perishable food 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. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

Technical assistance provided for FIT testing:

1. Facility Administrator will conduct FIT testing for all staff, document will need to be submitted to LPA on or before Sept. 17, 2021.

Administrator stated she'll do the following: (technical assistance provided)

Exit interview conducted. Copy of report provided.