Facility Evaluation Report

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Luzviminda Bulosan and explained the purpose of the visit. There are 3 residents ages 60 and above. The facility has a Dementia waiver, and a hospice waiver for 2 residents. Facility is a single story home located in a residential area consisting of 4 bedrooms (2 shared & 2 private), living room/dining area, kitchen, outdoor covered patio area, shed, and laundry area located in the backyard porch area. There is a detached garage in the rear of the property presently being used as storage and staff "resting area". The last emergency disaster drill was conducted on 5/17/2022. Administrator certificate expires 9/25/2022.

The following was inspected and observed during the inspection:

The interior and exterior physical plant was inspected.

Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical

distancing. Facility has an approved COVID-19 mitigation plan. LPA was screened upon entry by staff.

Room # 4 is designated as the COVID-19 isolation room if needed.

Three (3) centrally stored resident medication records were reviewed.

Due to cognitive impairment residents in care do not wear masks.

Sufficient supply of perishable for 2 days & non-perishable foods for 7 days was observed.

A posted Emergency Disaster Plan was observed.

Sufficient supply of Personal Protective Equipment (PPEs) was observed.

Both exterior side gates had locks on the exit doors. The locks were immediately removed.

A couch, foldable beds, bed, and staff personal belongings were observed. Administrator stated it is "sometimes" used by Administrator/Licensee & spouse to rest between shifts. The plan of operation staffing plan and facility sketch does not indicate the garage is to be used as a staff room. "Between 10 pm and 6 am, at least one staff person shall be awake and on duty if any resident with Dementia .... require night supervision."

Exit interview was conducted with Luzviminda Bulosan . A copy of the report and appeal rights were issued.