Facility Evaluation Report

Licensing Program Analyst (LPA) James Sampair conducted an infection control annual inspection of the facility. Upon entry into the facility, LPA observed that 3 of 3 staff members were wearing facial covering. They followed all of the required steps necessary for visitors to control infections including asking for his vaccination status and the use of a screening station near the entrance. COVID-19 signs were posted in common areas to promote hand washing and physical distancing and staff document temperature and health status of staff and residents on a daily basis. The LPA explained the purpose of the visit with Licensee and designated Infection control leader Julieta Basbas, who toured the inside and outside with the LPA.

Ms. Basbas reported that all staff and residents were fully vaccinated. The LPA observed that the temperature within the facility was maintained at a comfortable temperature, as was the hot water that was at 110 degrees Fahrenheit. There were sufficient food and water supplies, which were appropriately labelled. The Smoke and Carbon monoxide detectors were fully operational. and the fire extinguishers were fully charged and last replaced May of 2021.

The facility was cited for 2 Type B deficiencies, the details of which are in the LIC809-D:

Physical Plant/Environmental Safety - Type B: 87303(a) - broken hand railing on deck, both gates at front of facility are broken, shed door is broken, broken equipment and other refuse in backyard.

Disaster Preparedness - Type B: 1569.695(a)(2) - existing disaster and emergency plan lacking specific procedures for this facility and a lack of 72 hours of emergency food and water at the facility.

Exit interview was conducted and a copy of this report and copies of the Appeal Rights were provided.