Facility Evaluation Report

Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct an Annual Required inspection and met with Mylene Dado, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. LPA conducted Risk Assessment with Administrator.

Upon arrival, LPA observed facility with no posters outside entrance of facility pertaining to COVID-19 and advised Administrator to put up COVID-19 signs outside facility. LPA had temperature checked by Administrator but was not asked the screening questions and temperature was not documented at the entrance. LPA advised Administrator to add a sign-in sheet and have screening questions readily available. Administrator put the screening questions and sign-in sheet at the entrance.

LPA conducted a walk-through of the facility with Administrator and observed COVID-19 posters throughout the facility including hand washing posters in bathrooms. Hand sanitizer is available throughout the facility. Restrooms have hand hygiene products. The two clients were present at the time of visit and were both wearing surgical masks. Facility has submitted a mitigation program plan and was approved on 3/29/21. Facility has a 30-day supply of medication for clients. Facility has a designated visitation area. Facility has not conducted staff training on infection control and LPA advised facility to conduct training and document training. Clients currently do not attend in-person program but attend program virtually. Administrator stated that commonly touched surfaces are not disinfected daily and LPA advised them to disinfect high commonly touched surfaces at least once a day. Facility cleans facility daily. Facility has 30 day supply of Personal Protective Equipment (PPE) including but not limited to surgical and N-95 masks, gowns and hand sanitizer. Facility has a 100% vaccination rate of staff and clients are vaccinated.

During facility tour, LPA observed fire extinguishers were last charged in April 20, 2021. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to clients. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot tub in the back yard is covered and secure (LPA took photos of jacuzzi). LPA observed alcohol in refrigerator and Administrator immediately took out alcohol and locked it. (LPA took photos of alcohol)