Facility Evaluation Report

On 11/01/2022 at 12:50 p.m. Licensing Program Analyst (LPA), Evelin Rios, conducted an unannounced Annual Required visit at the facility mentioned above. LPA was greeted by staff #1 (S1) who granted access. Upon entrance, LPA's temperature was read and LPA was asked to sign in. Administrator, Stephanie Domingo joined us shortly after the physical tour was concluded. LPA informed Administrator of the purpose of the visit. At approximately, 1:00 p.m. a physical tour was conducted with S1 and LPA observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 03/03/2021) to make sure licensee was following current infection control recommendations. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. S1 stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility have fitted lids.

Kitchen/Breakfast table: LPA toured the kitchen area and observed staff #2 (2) preparing food for residents. LPA observed non-perishable food for 7 days and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. Cleaning supplies were locked in a kitchen cabinet under the sink. LPA asked S1 the name of S2 that was preparing food and helping with feeding residents. S1 stated S2's name. Administrator confirmed S2's name. LPA asked if S2's criminal background was cleared. S1 stated "Guardian status still said pending". Administrator confirmed they were still waiting for criminal background clearance.

Living Room: LPA observed living room to be clean and furniture appeared to be in good repair. A fire place was observed but not being used.

Smoke detectors/carbon monoxide . Dual smoke and carbon monoxide detectors were located throughout the facility, and at 1:50 p.m. they were tested and observed to be operational.