Facility Evaluation Report

Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Maria Engreso. The focus of the visit was Infection Control. Administrator Dante Encarnacion was grocery shopping and arrived a short time later. The facility was toured with Ms. Engreso and the following was observed: The facility is over capacity by 7 residents.

Covid signs were posted in the facility and a sanitization station was set up near the front entrance. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. Administrator Certificate for Dante Encarnacion was posted and expired on 3/30/23. Restrooms observed contained soap, paper towels and toilet paper. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. Social Distancing and masks were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured medication room for resident medication and files. All residents have at least a 30 day supply.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of mask wearing and hand washing for staff, visitors and residents. Administrator was reminded to review Department PINS in regards to Masking, Staff Testing, Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment.

See LIC809D for cited deficiencies. An exit interview was conducted and a copy of this report was provided to Dante Encarnacion.