Facility Evaluation Report

On 8/11/2022 at 12:10 PM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an infection control annual inspection. LPA met with S1, LPA called Assistant Administrator Edwin Isip and inform him the purpose of the visit. At 12:50PM Administrator Ryan Busalacchi arrived at the facility. Facility has census of 6.

LPA toured the facility inside and outside. LPA observed 1 resident eating lunch, S1 stated that other residents are out and attending their day programs. Facility has enough supplies of PPEs, paper supplies and hygiene supplies. 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 (mask). Facility has a mitigation plan and infection control plan. Facility maintains record of routine screening for residents and staff. Visitors policy is posted on the front entrance.

There was at least 7 days of nonperishable and 2 days of perishable foods. Smoke and Carbon monoxide detectors were operational. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. Smoke detectors and carbon monoxide were in operating condition during visit.